20110228 Ver 1_Application_20110309

201 10228
PA If ID
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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 CP30. This Application cannot be used
for wetland or stream impacts. Please provide seven?J copies of this application and supporting
information as well as a non-refundable application fee to the Division of Water QuafiAy of 24& t
for im bottom of less than 1 acre and $570.00 for impacts to lake bottom of greater
or equal to 'I acre.
Applications should be sent to: 12@ `
D 1(5? M
Division of Water Quality 401 Oversight/Express Review Permitting
"
1650 Mail Service Center
Raleigh, NC 27699-1650 MAR 9 2011
1. Applicant Information DENR -WA 12
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1. Owner/Applicant Information 8r?neh
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` Name: _l1 ounKS Jo Set L 6:t
Mailing Address: JrJT BAL. CrY rn e,T E C T-
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Telephone Number: 70 y` ?O1 t? f 52, Fax Number:
E-mail Address: 'ZAI Aelr1 S . Ca
2. Agent Information (A signed and dated copy of the Agent Authorization letter rnust be attached
if the Agent has sig,?natory authority for the owner/applicant.)
Name: ober? (JL?ttA ?t1
Company Affiliation: _Nt4radqr
Mailing Address: 10521'i f (k?) Uf';? ,?{ , IiJaOt , AJC. a
'T'elephone Number: rlbq- q-3g- 0_6 Fax Number:
E-mail Address: Tbu edq(',?iclt(t?S?YPQ/y7?nef
If. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local landmarks such
as towns, rivers, and roads. Also provide a detailed site plan showing property boundaries and
development plans in relation to surrounding properties, 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: ? pnJ? Nearest Town: M 1 ee -
Subdivision name; or site address (include phase/lot number):
Directions to site please include road numbers, landmarks, etc. (This is not necessary if an adequate
vicinity reap is included): Zy Zrj {0 rc '73? R- 00 Lr ((ys ? C i { ,
+Caa 6'01Q- I-A
CV)
2. Describe the existing land use or condition of the site at the time of this application.
3. Property size (acres):
ELY
4. Nearest body of water (strearn/river/sound/ocean/lake)-. L,9"?6_ f 1f
5. Describe the purpose of the proposed work: (5 Age.,T1, G vrf?sbtItZr, 4A Ot/
6. List the type of equipment to be used to construct the project: i /e%1 LDS
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls, etc.) below the
normal pool lake level in square feet or acres: 9d X 3 ,270 51r
$.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:
f4 k 3 2,7 a 6d f
8.b. Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance): ?fl?iQ r%+?pt ID dA4JI r S
Applicant/Agent'Vignafure Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

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