20100967 Ver 1_401 Application_20101117

20100867
The following is an abbreviated application form for those applying for a 401 Water Quality
Certification to impact FLRC (Federal. Energy Regulatory Commiesion} regulated lake shore or
bottom under the U.S. Army Corps of Engineers Permit GP30. This Appltcation cannot be used
for wetland or stream impacts. Please provide seven (7) copies of this application and supporting
information as well as a non-refundable application flee to the Division of Water Quality of $240.00
for imparts of to lake bottom of less tban 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 Ovemght/Express Review Permitting
1550 Mail Service Center Raleigh, NC 276991650 il Mau
I. Applicant Information V I ! Zn,
v?reDE' WATER WaLirr
1. Owner/Applicant Information ?ro?rc?;?,,;,,?R e
j
Name
Al 71
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
2. Agent Information (A signed1wd dated copy of the Agent Authorization letter must be attached
if the Agent has signatory authority for the owher/applicant.)
Name:
Company Affiliation:
Mailing Address:
Telephone Number. Fax Number.
E-mail Address:
lZ Project Information
Attach a vicinity map clearly showing the location of the property with respect to local landmarks such
is towns, rivers, and roads. Also provide a detailed site plan showing property boundaries and
ievelopment plans in relation to surrounding properties. You may use the diagram below to make a
land sketch of your project. Also, see the example below for guidance. Both the vicinity map and site
)Ian must include a scale and north arrow. The footprints of all buildings, impervious surfaces, or other
acilities must be included.
Location
County: Nearest Town:
Subdivision name or site address (include phase/lot number): IS,G''l
'all
Directions to site please include road numbers, landmarks, etc. (This is not necessary if an adequate
vicinity map is included): zfe ?? ?i.?d?? GP.??/?, ?,?+ f 1?i I s? 2
2. Describe the existing land use or condition of the site at the time of this application:
3. Property size (acres):
4. Nearest body of water (stream/river/sound/ocean/lake): 4 1,
5. Describe the purpose of the proposed work: c'L-C?
1leiy
6. List the type of equipment to be used to construct the project:
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls,, etc.) below the /
normal pool lake level in square feet or acres:
8.a. Amount of impact (including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
above the normal pool lake level and 50 feet land-ward in square feet or acres:
8.b. Please describe vegetation above the normal of lake levelarut
0 feet andward to be impacted
(number of trees for instance): e. ld/dl e!!ww ?Sf

/10
signature is valid only if an authorization letter from the applicant is provided.)

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