20031265 Ver 3_401 Application_20100504

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The following is an abbreviated application form for those applying for a 401 Water Quality
Certification to impact FERC (Federal Energy Regulatory Commission) regulated lake shore or
bottom under the U.S. Army Corps of Engineers Permit GP30. This Application cannot be used
for wetland or stream impacts. Please provide five (5) copies of this application and supporting
information as well as a non-refundable application fee to the Division of Water Quality of $240.00
for impacts to lake bottom of less than 1 acre and $570.00 for impacts to lake bottom of greater or
equal to 1 acre.
Applications should be sent to:
Division of Water Quality 401 Oversight/Express Review Permitting
1650 Mail Service Center
Raleigh, NC 27699-1650
1. Applicant Information
rAJ-D-
IOwner/Applicant Information
Name: FAtAL 4 PN y L1,i4 is y?-OU 5KY
Mailing Address: y i LF+ {L E /Zoy?}
?v??Sau1?, Iy (_ ?.7?4q
Telephone Number: a Sul 3 11 Fax Number: N
E-mail Address: S1 LLy-PLJ19 R0L. ?f1i
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be attached
if the Agent has signatory authority for the owner/applicant.)
Name:
Company Affiliation: w vt`
Mailing Address: "Ar 4 2010
Telephone Number: Fax Number: S?wOSAi,.. h
E-mail Address.
II. Project Information
Attach a vicinity mop clearly showing the location of the property with respect to local landmarks such
as towns, rivers, an# moods. Also provide a detailed site plan showing property boundaries and
development planq to relation to surrounding pfoperties. You may use the diagram below to make a
hand sketch of your project. Also, see the example below for guidance. Both the vicinity map and site
plan must include a scale and north arrow. The footprints of all buildings, impervious surfaces, or other
facilities must be included.
1. Location
County: F rg Acs K LiNearest Town: R U /J /\J
Subdivision name or site address (include phase/lot number): /lal -S/44}M oA I?R 1 ?- - ?-a o da?
KOVAL-
Directions to site please include road numbers, landmarks, etc. (This is not necessary if an adequate
vicinity map is included): ???'+ w4?cE aizeST TAKE R-uTE WGAI<S /tT -kt P ay ?3yNtj
Cro ST'ralk4T -MF-L?, io ?--A/41LC,S ,SAKE Aik-4r
a "+o Xd)GC Ro O, EN7'_&JC6 To L-4C- AZoYA+.L- IS I mli.E 0? L4af 1".
2. Describe the existing land use or condition of the site at the time of this application: Hon4'c
3. Property size (acres): ? ? A e R it
4. Nearest body of water (stream/river/sound/ocean/lake): L_4 kC
5. Describe the purpose of the proposed work: 14cA y go A.T VWV C u 0, S C A,%Scl b kiz
"AeLA-T1Jc ,y MCA N 04t.NC4 +0 twbcRAI/J'2°4 0Av?E MiCSOA GI-4S(sN bal4iNb IT. R-ACOAel)+
ffiF Ft?3? IQ `l^ /??P-f;A f' ??-? uE Yur u j?f-N?r?rr?!s WwL .STo f
?-I_o A% g r'TERt V
6. List the type of equipment to be used to construct the project: S,MAtL 1<00SQAT JEAoSmEl 2%P-RA 4
fi,&" mA,-rsZ%AV r'ReP+ IbEIf#PD Tt+E ?j45? b t}!7. Sp?seE HAWOWoLK, LOILL k NcebO
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls, etc.) below the
normal pool lake level in square feet 44? acres: Ki?KaP -?0 8g AAc..-b A??,r11r ?? iinY' Bay so ,.r6
t. Nke ?PPft-b, SFT , r k a? 1 &%-art o d,?,-rH -(Ibes c . 0O,*V+0%45
O? ?A--. 19B' +'?7 s?corJD AIZSA? ?osc?sr-1-
A A
8.a. Amount of impact (including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
above the n_(1mal pool lake level and 50 feet land-ward in square feet or acres:
l IMDUCT LA,.-.= =. L1V_£A Acl1l.,s
N I-o D ED Ssott_ x IqO& Y 91 ? 6_ri AkcA ?7 2 P+ X f r- ' = Lam SQ
8.b. Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance): Ahoy
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
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