20110399 Ver 1_Shoreline Stabilization_20110426

201 10398
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 I
1. Owner/Applicant Information
R [9 ME I
APR 2 6 ZOO
DENR . WATER QUALITY
Name: ? fin, AC's C, 71C e Z T\e WETLANDS AND S100TER BRANCH
Mailing Address: SSS ?Aa k n Q-( Rv e-
Telephone Number: F)'2-% -RS] ©10 9 Fax Number:
E-mail Address:
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:
Compa
Mailing Address: 17, 1Ls? LAL ?c c h , . _12 `10, "Sk J ; 1 e J iO C 2 ?6
Telephone Number: 2`xu - y ?; 5 - t 2 -1 Fax Number:
E-mail Address: 4?'2 tW\ L\'tL??Kil?? C
H. 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.
US Army Corps Of Engineers Field,Of6ces and County Coverage
Asheville Regulatory Field Office Alexander Cherokee Iredell
kson
J Mitchell
Polk
US Army Corps of Engineers Avery
Buncombe Clay
Cleveland ac
Lincoln Rowan
151 Patton Avenue Burke Gaston Macon Rutherford
Roan 208 b Graham Madison Stanley
Asheville, NC 28801-5006
Telephone: [phone] arus
Ca
Caldwell Haywood
d McDowell
Mecklenbur Swain
Transylvania
Fax: [phone] Catawba erson
Hen g
Raleigh Regulatory Field Office Alarnance
b
ll Dud=
coombe
l d Johnston
Lee Rockingham
Stokes
US Awry Corps Of Engineers arty
eg
A
Ashe g
Franklin Nash Suay
6508 Falls of the Near Road Caswell Forsyth Northampton Vance
Suite 120
Raleigh, NC 27615 Chatham Granville Orange Wake
ren
Wa
Telephone: [phone] Davidson Guilford Person
l
h
d r
Wilkes
Fax: [phone] Davie Halifax p
o
Ran
Washington Regulatory Field Office Beaufort Cumtuck Jones
i
US Army Caps Of Faginoas Bade Dan Leno
r i

Post Office Box 1000
Camden
Gates rt
li

Wathhi8tan, NC 27889-1000
Carteret*
t (h Green
Hertford co
Pam
Palk
Telephone [phone] owan
.
Hy
Perqnimans
Fax: [phone]
Wilmington Regulatory Field Office ,
V Duplin
?
t Onslow
Pender
US Army Corps Of Firgumars B laden
Brunswick Harnet
Hoke Richmond
Post Office Box 1890
Wilmington, NC 28402-1890 Carteret Montgomery Robeson
Telephone. [phone] Columbus
mberland
C Moore
New Hanover Sampson
Scotland
Fax: [phone] u
US Fish and Wildlife Service / National Marine Iliheries Service
US Fish and Wildlife Service
Raleigh Field Office
Post Office Box 33726
Raleigh, NC 27636-3726
Telephone: [phone]
Division of Water Quality
401 Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
Telephone: [phone]
Fax: [phone]
US Fish and Wildlife Service
Asheville Field Office
160 Zillicoa Street
Asheville, NC 28801
Telephone-. [phone]
Pitt
Tyrrell
Washington
Wayne
Union
Watauga
Yancey
Wilson
Yadkin
•Croatan National Forest Only
National Marine Fisheries Service
Habitat Conservation Division
Pivers Island
Beaufort, NC 28516
Telephone: [phone]
North Carolina State Agencies
Division of Water Quality
Wetlands Restoration Program
1619 Mail Service Center
Raleigh, NC 27699-1619
Telephone: [phone]
Fax: [phone]
State Historic Preservation Office
Department Of Cultural Resources
4617 Mail Service Center
Raleigh, NC 276994617
Telephone: [phone]
Fax: [phone]
CAMA and NC Coastal Counties
Beaufort Chowan Hertford Pasquotank
Division of Coastal Management Bertie Craven Hyde Pender
Mail Service Center
1638 Brunswick Cuaituck New Hanover Perquim-anc
Raleigh, NC 27699-1638 Camden Dare Onslow Tyrrell
Telephone: [phone] Carteret Grates Pamlico Washington
Fax: [phone]
NCWRC and NC Trout Counties

Western Piedmont Region Coordinator
Alleghany Caldwell
Mitchell Watauga
Wilkes
3855 ldlewdd Read Ashe
Avery Stokes
tok
1Cerrersville, NC 27284-9180 Burke y
S
Telephone [phone]

Mountain Region Coordinator Buncombe
Cherokee Henderson
Jackson Polk
Rutherford
20830 Great Smoky Mtn. Expressway clay
y Macon Swain
Waynesville, NC 28786 ham
G Madison Transylvania
Telephone: [phone] ra
Fax:-[phone] Haywood McDowell Yancey
Angeliquo Bumgarnor
DBA: Permits Unlimited
8165 Church Rd.
Taylorsville, NC 28681
828-455-1327
[e-mail]
Juanita Green
KRG Utility, Inc
555Harper Ave. Ste. B
Lenoir, NC 28645
Ph. 828-851-0109
Wk: 828-757-0006
RE: Revision - Dock & Shoreline Stabilization
0 $1
-
h0Q"QbeL 18, 2010
On this 18th day of October, 2010. I z) UAll T1, S . ?2PQn?e give Angelique Bumgarner /
Permits Unlimited, permission, on my behalf to complete all documentation and forms to attain permits
required by Alexander County, Duke Energy Lake Management, NC Habitat Enhancement, NC Division
of Water Quality, and US Army Corps of Engineers for the completion of my private dock and shoreline
stabilization located at: 8281 Church Rd., Taylorsville, NC 28681.
Fees Include:
Duke Power $300.00 x 1: $300.00 (pd.)
Alexander County Permit x 1: $194.20 (pd.)
Alexander County Zoning x 1: $25.00 (pd.)
US Army Corps of Engineers $0.00
NC Division of Water Quality $240.00
NC Habitat Enhancement $250.00 x l: $250.00 (pd.)
1LY@RflFr-'-:y
D
APR 1 2 2011
OENR • WATERQUWTY
?lETlgHpgq??
Please enclose a check to NC Division of Water Quality for the sum of $240.00 along with the enclosed
forms signed and dated. Thank you for your business. If you have any questions or concerns please
contact me anytime.
Juanita Greens .
C" Date
74
Angelique Bumgarner
ate?
Respe tfu y,
AA .
'Pete
Angelique B. Bumgarner
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Reports
Alexander County, NC
Tax Parcel Report
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*WARNING: THIS Thursday,
IS NOT A SURVEY! 10/14/2010
* X
This map is prepared
for the inventory of
real property found
within this
jurisdiction, and is
compiled from
recorded deeds, plats,
and other public
records and data.
Users of this map are
hereby notified that
the aforementioned
CCT NO: 313505
PROPERTY NO: 1 100023
AP NO: C11C
OT NO:
NAME: 022
REEVE
ANITA &
DDR: O BOX 2000
FCTYST: ENOIR NC
F- F-
http://maps. co.alexander.nc.us/GoMaps/reports/report.cfm?CFI... 10/14/2010
Reports
public primary
information sources
should be consulted
for verification of the
information
contained on this
map. The County and
mapping company
assume no legal
responsibility for the
information
contained on this
map.
Page 2 of 2
IPCD: 28645
REF1: 11053915012010
CRES: .490
AL: 11146238
SUBDIV:
OCATN: 53 SEC. 5 .11
ESCRIPTION: CHURCH RD
http://maps.co.alexander.nc.us/GoMaps/reports/report.cfin?CFI... 10/14/2010
? r
Location
County: ?2X?i <1??C Nearest Town: ??,?u?oCS?) i ?? e
Subdivision name or site address (include phase/lot number): `2F?1 ?,r,(c ?n Q?TZ?t 5-3
Directions to site please include road numbers, landmarks, etc. (This is not necessary if an adequate
vicinity map is included):
Ij'1Me f v ?. y Q\T I PoA C7t ?tiUP `;a , pQ&-p iG,Q ynIt?Q ef-l 1 +J-1- n
?e&-?- ANO 0 ki-, 'V u 10" i? ?,p P ? c\kA-rdl, c i Z I ?2 Cz nt)h
2. Describe the existing land use or condition of the site at the time of this application:
3. Property size (acres): - 'Iq Q 6_r f e S
4. Nearest body of water (stream/river/sound/ocean/lake):
5. Describe the purpose of the proposed work: f -;? ,o .
6. List the type of equipment to be used to construct the project: TnR ?Yv- V)?CL: - .
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:
LA 1.9;
8.b. Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance): Crx -, ?. U , t , n
-in-
Appli(#nt/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Please approximately sketch the fopowing information on this plan
(please provide dimensions for each Item, such as 10 f#. x 100 ft):
1) All proposed vegetation clearing (provide dimensions).
2) Location of rip rap or fill to be placed above the Fug Pond-elevation
3) Location of rip rap or fill to be placed below the Full Pond elevation
4) The location of any proposed structures such as buildings, retaining
walks docks, etc.
6) The location of any excavation or dredging below the Full Pond
elevation.
6) Location of construction access corridors.
http://www.mapsonus.com/mapsonus/printmapisp f z5n,-=
Notes:
2321 Crabtree Blvd, Raleigh, NC 27604-2260
0.3 miles
Depart Crabtree Blvd toward Timber Dr
1. Turn right onto Capital Blvd 0.1 miles
2. Keep straight onto US-401 North / Capital Blvd 0.7 miles
3. Keep straight onto US-1 North / US-401 North / Capital Blvd 0.0 miles
4. Take ramp right for 1-440 West / Cliff Benson Beltline toward Outer Beltline / Sanford 6.8 miles
5. Al exit 413, take ramp right for Wade Ave toward Durham / Rdu Intl Airport 3.3 miles
6. Keep straight onto 1-40 West / Dan K Moore Fwy 30.7 miles
7. Bear right onto 1-40 West / 1-85 South / SR-86 TRUCK North 30.8 miles
8. Keep right onto 1-40 South / 1-85 Bus West 7.7 miles
9. Keep straight onto 1-40 West / US-220 South 80.5 miles
10. At exit 138, take ramp right toward Catawba / Oxford School Rd 0.2 miles
11. Turn left onto Shad Ln 0.1 miles
12. Turn right onto Oxford School Rd 2.1 miles
13. Turn left to stay on Oxford School Rd 3.6 miles
14. Turn right onto SR-16 / NC Highway 16 N 3.5 miles
15. Turn left onto Wayside Church Rd 1.2 miles
16. Turn left onto Rink Dam Rd 1.8 miles
17. Turn left onto Church Rd 1.7 miles
M Arrive at Church Rd at 8281 Church Rd, Taylorsville, NC 28681-7387
2 of 2 4/10/20114:43 PM
ALEXANDER COUNTY
Inspections
6125 NC MW 16 S Taylorsville, NC 28681
Telephone: [phone] Fax: [phone]
BUILDING
PERMIT
Permit Number: 6110
Location:
Permitted Use:
This permit must be posted on the job site,
and must be visible from the driveway or the
main entrance to the property.
0000
Inspector: L7-
Date:
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DUKE ENERGY LAKE SERVICES
EC12-Q
P O BOX 1006
CHARLOTTE, NC 28201-1006
704-382-1567 or TOLL FREE 1-800-443-5193
APPLICATION FOR PERMIT TO STABILIZE THE SHORELINE IN NORTH CAROLINA
Please type or print and fill in all blanks. If information is not applicable, so indicate by placing N/A in blank. PLEASE
SUBMIT APPLICATION AND APPROPRIATE DUKE ENERGY FILING FEE, PAYABLE TO DUKE ENERGY,
TO ABOVE ADDRESS.
1. Applicant Information
A. Name ?-y(,h?_? n1?\ P<l e
B. Mailing Address r )C-
C. Telephone:
C.
if. Location of Proposed Project
A. Lake Ui
B. Street Address ? 551 C h ?cc h .
C. County .E
D. City, town, community or landmark C •"
E. Section 6- Lot #-` Subdivision
F. Directions to property by road r„i_g ai1 e,,??-
--<
G. Latitude and longitude for the project site 3 J , ,? 1,0 :z- 1__,,,=f? 1, Z.5 i Z
H. Please submit a map showing the coordinates or a detailed map (USGS quad"map, city map, etc.) showing the
exact location of the project site. (NOTE: Latitude/ longitude coordinates can be found on internet site,
www.ma[)sonus.com. Directions: Don't register, click "Maps", enter address, draw map, select "Map Clicking
Will...", select "Lat/Long", click map)
III. Description of Project
A. Length of wall__
B. Material RCp?W
C. Distance from property line/shoreline ]"ol1?cu?ln7_,e ; fina (C nQ
IV. Intended Use of Project Area
A. Private? C rY,
B. Commercial
V. Applicant Signature Date
PLEASE NOTE. THE FOLLOWING:
• 2 COPIES OF THE "DUKE ENERGY APPLICATION FOR PERMIT TO STABILIZE THE SHORELINE IN NORTH
CAROLINA", PHOTOGRAPHS OF THE SHORELINE TO BE STABILIZED, AND FIVE (5) COPIES OF THE
COMPLETED "NC DIVISION OF WATER QUALITY PRE-CONSTRUCTION NOTIFICATION APPLICATION"
MUST BE SUBMITTED WITH THE DIVISION OF WATER QUALITY APPLICATION FEE TO:
NC DIVISION OF WATER QUALITY
ATTENTION. CYNDI KAROLY
PARKVIEW BLDG., 2321 CRABTREE BLVD.
RALEIGH, NC 27604
919-733-1786
YALAKEMGMnPackage Information\NC Shoreline Stabilization Application.doc
? Drivin?, Directions from Raleigh, North Carolina to 8281 Church Rd,... http://www.mapquest.com/print?a=app.core.c5f801104%684f4d18ea02
mapquest Notes
Trip to:
8281 Church Rd
Taylorsville, NC 28681-7387
180.40 miles
3 hours 15 minutes
Raleigh, NC 27699 Miles Per Miles
Section Driven
1. Start out going SOUTH on SOLHEIM LN toward CUPP Go 0.1 Mi 0.1 mi
CT.
2. Turn LEFT onto MEDIATE DR. Go 0.06 Mi 0.2 mi
r 3. Take the 1st RIGHT onto SUGARLOAF WAY. Go 0.07 Mi 0.3 mi
If you reach the end of MEDIATE DR you've gone a little
too far
41 4. Take the 1st LEFT onto SEASTONE ST. Go 0.06 Mi 0.3 mi
If you are on INKSTER CV and reach ROCCA CIR you've
gone a little too far
41 5. Turn LEFT onto OLD STAGE RD. Go 3.5 Mi 3.8 mi
6. Turn RIGHT onto FAYETTEVILLE RD / US-401 N. Go 3.0 Mi 6.8 mi
4-° Continue to follow US-401 N.
US-401 N is 0.1 miles past GROVEMONT RD
1 t 7. Merge onto 1-40 W via the ramp on the LEFT toward Go 71.1 Mi 78.0 mi
CARY/DURHAM.
If you reach PENMARC DR you've gone about 0.1 miles
too far
a 8. Keep RIGHT to take 1-40 W via EXIT 131 toward 1-70 / Go 88.3 Mi 166.2 mi
GREENSBORO / WINSTON-SALEM.
9. Take EXIT 138 toward NC-10 W / OXFORD SCHOOL RD Go 0.2 Mi 166.4 mi
/ CATAWBA.
+1 10. Turn LEFT onto SHAD LN. Go 0.06 Mi 166.5 mi
r 11. Take the 1st RIGHT onto OXFORD SCHOOL RD. Go 2.1 Mi 168.6 mi
If you reach 1-40 W you've gone about 0.1 miles too far
12. Turn LEFT to stay on OXFORD SCHOOL RD. Go 3.6 Mi 172.2 mi
1 of 3 4/3/2011 11:52 PM
Drivi?r; Directions from Raleigh, North Carolina to 8281 Church Rd,... http://www.mapquest.com/print?a=app.core.c5f8011e740b684f4d] 8ea02
r 13. Turn RIGHT onto NC HIGHWAY 16 N / NC-16. Continue Go 3.5 Mi 175.8 mi
i? to follow NC-16.
?1 14. Turn LEFT onto WAYSIDE CHURCH RD. Go 1.2 Mi 176.9 mi
WAYSIDE CHURCH RD is just past FRED JOLLY LN
41 15. Turn LEFT onto RINK DAM RD. Go 1.8 Mi 178.7 mi
RINK DAM RD is 0.2 miles past CHESTERFIELD DR
+1 16. Turn LEFT onto CHURCH RD. Go 1.7 Mi 180.4 mi
CHURCH RD is just past POLY BOWMAN RD
17. 8281 CHURCH RD is on the LEFT. 180.4 mi
If you reach the end of CHURCH RD you've gone a little
too far
8281 Church Rd 180.4 mi 180.4 mi
Taylorsville, NC 28681-7387
2 of 3 4/3/2011 11:52 PM
Reports
Alexander County, NC
Tax Parcel Report
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*WARNING: THIS Thursday,
IS NOT A SURVEY! 10/14/2010
* x
This map is prepared
for the inventory of
real property found
within this
jurisdiction, and is
compiled from
recorded deeds, plats,
and other public
records and data.
Users of this map are
hereby notified that
the aforementioned
[ACCT NO: 9313505
PROPERTY NO: 0002310
P NO: C1 1C
OT N0: 10022
NAME. GREENS
ANITA &
DDR: O BOX 2000
CTYST: ENOIR NC

http://maps.co.alexander.nc.us/GoMaps/reports/report.cf n?CFI... 10/14/2010
Reports
Alexander County, NC
Tax Parcel Report
SURVEY!*
This map is prepared for the
inventory of real property
found within this jurisdiction,
and is compiled from recorded
deeds, plats, and other public
records and data. Users of this
map are hereby notified that
the aforementioned public
primary information sources
should be consulted for
verification of the information
contained on this map. The
County and mapping company
assume no legal responsibility
for the information contained
on this map.
http://maps.co.alexander.nc.us/GoMaps/reports/report.cfm?CFID= 11...
ACCT_NO: 9313505
PROPERTY NO: 0002310
MAP-NO: C 11 C
?LOT_NO: 0022
NAME: GREENE JUANITA &
DR: PO BOX 2000
CTYST: ENOIR NC
ZIPCD: 28645
?DREFI: 053915012010
ACRES: .490
VAL: 146238
SUBDIV:
LOCATN: 53 SEC. 5
DESCRIPTION: HURCH RD
1 of 1 11 / 18/2010 10:14 AM
*WARNING: THIS IS NOT A Thursday, 11/18/2010
w
Office Use Only: Form Version March 05
USACE Action ID No. DWQ No.
(If any particular item is not applicable to tins project, please enter ivot Appiicanie or N/A .)
I. Processing
1. Check all of the approval(s) requested for this project:
? Section 404 Permit ? Riparian or Watershed Buffer Rules
? S tion 10 Permit ? Isolated Wetland Permit from DWQ
O1 Water Quality Certification ? Express 401 Water Quality Certification
2. Nationwide, Regional or General Permit Number(s) Requested:
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ?
4. If payment into the North Carolina Ecosystem Enhancement Program (NCEEP) is proposed
for mitigation of impacts, attach the acceptance letter from NCEEP, complete section VIII,
and check here: ?
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Management Area of
1?nvironmental Concern (see the top of page 2 for further details), check here: ?
II. Applicant Information
1. Owner/Applicant
Name: AA ka
Mailing Address:,
Telephone Number: 425& Fax Number:
E-mail Address:
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be a ached if the Agent has signatory authority for the owner/applicant.)
Name: Y%.
Company Affil ion:
Mailing Address: `k\ ,E2
Telephone Number: ':A '23 2- Fax Number:
E-mail Address: VQ rte, cc
Page 5 of 12
Angoliquo Bumgarnor
DBA: Permits Unlimited
8165 Church Rd.
Taylorsville, NC 28681
828-455-1327
[e-mail]
Juanita Green
KRG Utility, Inc
555Harper Ave. Ste. B
Lenoir, NC 28645
Ph. 828-851-0109
Wk: 828-757-0006
RE: Revision - Dock & Shoreline Stabilization
0$1-
yyo9"etiez 18, 2010
On this 18th day of October, 2010.1 ??iL?J12c T?? ?9 dkePn give Angelique Bumgamer /
Permits Unlimited, permission, on my behalf to complete all documentation and forms to attain permits
required by Alexander County, Duke Energy Lake Management, NC Habitat Enhancement, NC Division
of Water Quality, and US Army Corps of Engineers for the completion of my private dock and shoreline
stabilization located at: 8281 Church Rd., Taylorsville, NC 28681.
Fees Include:
Duke Power $300.00 x 1: $300.00 (pd.)
Alexander County Permit x 1: $194.20 (pd.)
Alexander County Zoning x 1: $25.00 (pd.)
US Army Corps of Engineers $0.00
NC Division of Water Quality $240.00
NC Habitat Enhancement $250.00 x 1: $250.00 (pd.)
&C?[g0F
D
APR 1 2 2011
DENR• WATER QUVM
Please enclose a check to NC Division of Water Quality for the sum of $240.00 along with the enclosed
forms signed and dated. Thank you for your business. If you have any questions or concerns please
contact me anytime.
Juanita Greeno.
V'V41'e_ Date
to
Angelique Bumgamer
r 7 j7,Date?
Respe tfu y,
x 4 S44u_
Angelique B. Bumgarner
III. 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. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project:,.,
2. T.I.P. Project Number or State Project Number (NCDOT Only): r3A
3. Property Identification Number (Tax PIN):
4. Location
\???;?
County: ??zltr'?c1 ?e? Nearest Town:
Subdivision name (include phase/lot number): 1{- :V- _ y
Directions to site (include road numbers/names, landmarks, etc.):
5. Site coordinates (For linear projects, such as a road or utility line, attach a sheet that
separately lists the coordinates for each crossing of a distinct waterbody.) r
Decimal Degrees (6 digits minimum): (2 $ ON °W
6. Property size (acres): , LM O 7. Name of nearest receiving body of water: L- (,)Q W\

8. River Basin:
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at http://h2o.enr.state.nc.us/admin/maps/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
Page 6 of 12
10. Describe the overall project in detail, including the type of equipment to be used:
11. Explain the purpose of the proposed
IV. Prior Project History
if jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application.
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. Each impact must be
listed separately in the tables below (e.g., culvert installation should be listed separately from
riprap dissipater pads). Be sure to indicate if an impact is temporary. All proposed impacts,
permanent and temporary, must be listed, and must be labeled and clearly identifiable on an
accompanying site plan. All wetlands and waters, and all streams (intermittent and perennial)
should be shown on a delineation map, whether or not impacts are proposed to these systems.
Wetland and stream evaluation and delineation forms should be included as appropriate.
Photographs may be included at the applicant's discretion. If this Rroposed impact is strictly for
wetland or stream mitigation, list and describe the impact in Section VIII below. If additional
space is needed for listing or description, please attach a separate sheet.
1. Provide a written description of the proposed impacts:
Page 7 of 12
C CA
L r
2. Individually list wetland impacts. Types of impacts
flooding
ti include, but are not
ditching/drainage, etc. limited to
For dams,
,
on,
mechanized clearing, grading, fill, excava
separately list impacts due to both structure and flooding Located within Area of
Wetland Impact Type of Wetland

forested, marsh,
act
Type of Imp 7(e.g., 100-year

Floodplain Eea Impact

(acres)

Site Number
ous, bog, etc.
erbace
dicate on map) )
i

(es/no
(
n
.0-
Total Wetland Impact (acres)
3. List the total acreage (estimated) of all existing wetlands on the property: il)I (
4. Individually list all intermittent and perennial stream impacts. Be sure to identify temporary
impacts. Stream impacts include, but are not limited to placement of fill or culverts, dam
construction, flooding, relocation, stabilization activities (e.g., cement walls, rip-rap, crib
walls, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is proposed,
plans and profiles showing the linear footprint for both the original and relocated streams
43,5600.. ea of
must be included. To calculate acreage, multiply len h X wilt Average divide by
aac
Stream Impact Perennial or Stream Width Length Impact
Number Stream Name Type of Impact Intermittent?
Before Impact (linear feet acres
ndicate on map)
Total Stream impact (by length and acreage)
5. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.). Open water impacts include, but are not limited to
fill, excavation, dredging, floodin , drainage, bulkheads, etcType of waterbody Area of
sound, ba Impact
Open Water Impact Name of Waterbody Type of
Type of Impact (lake, pond, estuary, y,
Site Number (if applicable) ocean, etc. (acres
(indicate on ma
Total Open Water Impact (acres)
Page 8 of 12
List the cumulative impact to all Waters of the U.S. resulting from the roject:
6
Stream Impact (acres): _ ry
Wetland Impact (acres): 5 265
open Water impact (acres): 0,0 060 Z -r
Total Impact to Waters of the U.S. (acres) , cx1 ??-
Total Stream impact (linear feet):
7. Isolated Waters [io
Do any isolated waters exist on the property? ? Yes
acts to isolated waters, and include the type of water
a note that this sechon)onldy
Describe all imp act (acres or linear feet). Plea
the size of the proposed imp the USACE.
applies to waters that have specifically been determined to be isolated by
8. Pond Creation 01 N proposed, associated wetland and stream impacts should be
If construction of a pond is prop the proposed pond should
included above in the wetland and stream impact sections. Also,
s included with this application.
be described here and illustrated on any map uplands ? stream ? wetlands
Pond to be created in (check all that apply): embankment, excavation, installation of
Describe the method of construction (e.g., dam/
,
.
draw-down valve or spillway, etc.): e livestock watering, irrigation, aesthetic, trout pond
Proposed use. or purpose of pond (.g•,
local stormwater requirement, etc.):
Current land use in the vicinity of the pond: Expected pond surface area:
Size of watershed draining to pond:
VII, Impact Justification (Avoidance and Minimization)
avoid the proposed impacts. It may be useful to provide
Specifically describe measures taken to a h building ordinances, accessibility, and
?j information related to site constraints such ogry attach drawings of alternative, lower-impact
3 financial viability of the project. The applicantma
site options were not feasible. Also discuss how impacts
layouts, and explain why these design hcable, discuss construction
were minimized once the desired. site plan was developed.
mpacts. app
' techniques to be followed during construction to educe
VIII. Mitigation the NC
nce with 15A NCAC 2H .0500, mitigation may be required by
DWQ _ accorda eater than or equal to one acre of impacts to involving _ Division of Water Quality for p ??antor equal tog150 linear feet of total impacts to perennial
freshwater wetlands or greater
streams.
Page 9of12
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on January 15, 2002, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCEEP concurrence shall be placed on hold as incomplete.
An applicant may also choose to review the current guidelines for stream restoration in DWQ's
Draft Technical Guide for Stream Work in North Carolina, available at
http•//h2o enr state nc us/newetlands/strmgide.html.
1. Provide a brief description of the proposed mitigation plan. The description should provide
`?Cas much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
2. Mitigation may also be made by payment into the North Carolina Ecosystem Enhancement
Q( Program (NCEEP). Please note it is the applicant's responsibility to contact the NCEEP at
[phone] to determine availability, and written approval from the NCEEP indicating
that they are will to accept payment for the mitigation must be attached to this form. For
additional information regarding the application process for the NCEEP, check the NCEEP
website at http://h2o enr state nc us/wrp/index.htm. If use of the NCEEP is proposed, please
check the appropriate box on page five and provide the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12

IX, Environmental Documentation (required by DWQ) funds or the use of
1. Does the project involve an expenditure- of public (federal/state/lo cal)
public (federal/state) land? ? i
Pursuant to the
es, does the project require preparation of an envro1 Policy Act document
2. If y (NEPA/SEPA)?
requirements of the National or North Carolina Environment is reqired Note: If you are not sure whether aNEPA/SEPA d for environmuental docall the cumentaEon.
coordinator at [phone] to review current thresholds
Yes ? No ?
3.?fyes, has the document review been finalized by the States Clearingh Nose if so, please
?? attach a copy of the NEPA or SEPA final approval letter. Ye
X. Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
It is the applicant's (or agent's) responsibility to determine, delineate 1 and austll impacts provide project.
cant
also required state and local buffers
Section associated
VlI abovehe All propos dei pacts must be listed herein,
justification for these impacts in in site plan. All buffers must be shown on a
mapand, must be clearly identifiable on t roaosed to the buffers. Correspondence from the DWQ
whether or not impacts are p p
Renal Office may be included as appropriate. Photographs may also be included at the
g
applicant's discretion.
1. Will the project impact protected riparian buffers identified
AC 02B 0243 (Catawba) 15A NCAC
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A Buffer Requirements), or other (please
2B .0250 (Randleman Rules and Yes r Supply o [
identify
the
amount of mitigation by applyi buffers
2. If "yes", identify the square feet and acreage of impact
If buffer mitigation is required calculate the required
buffer multi liers. Required .
\ Impact Multiplier Mitt ation
a? Zone* s uare feet
l' 1 3 (2 for Catawba)
2 1.5
[ Total I
* Zone 1 extends out 30 feet perpendicular from the top of the near bank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone 1.
3. If buffer mitig' ation is required, please discuss what type of mitigation is pr p mto lthe ent ?onation of Property, Riparian Buffer Restoration / nhanEnhancement, nformation as identified
?? Riparian Buffer Restoration Fund). lese 0244 Por x0260 attach all appropriate
within 15A NCAC 2B .0242 or .
Page 11 of 12
XI. Stormwater (required by DWQ)
Describe impervious acreage (existing and proposed) versus total acreage on the site. Discuss
stormwater controls proposed in order to protect surface waters and wetlands downstream from
the property. If percent impervious surface exceeds 20%, please provide calculations
demonstrating total proposed impervious level.
XII. Sewage Disposal (required by DWQ)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ? No
Is this an after-the-fact permit application? Yes ? No 2
XIV. Cumulative Impacts (required by DWQ)
Will this project (based on past and reasonably anticipated future impacts) result in additional
development, which could impact nearby ?cumulative impact analysis?in accordance with
If yes, please submit a qualitative or quantitative
the most recent North Carolina Division of Water Quality policy posted on our website at
hM.//h2o enr state nc.us/ncwetlands. If no, please provide a short narrative description:
XV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
_/,F-/D
j Applicant/Agent's Signature Date
Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 12 of 12