20110566 Ver 1_401 Application_20110614

20116566
The following is an abbreviated application form for those applying for a 401 Water Quality
Certilii cations to impact FMC (Federal Energy Regulatory Commi?i - 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 seven M copies of this application and snp
information as well as a non-refundable application fee to the Division of Water Quality al.
for impacts of 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: W_
Division of Water Quality 401 Oversight/Express Review Permitting ?-
1650 Mail Service Center `-i
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Raleigh, NC 27699-1650
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1. Applicant
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L Owner/Applicant Information ;; II 's 7L
Name: -ab,4 n:, L ---
Poo Mailing Address: _ 6 ci3 5- Li?.?t?f1 c? l.? Pc
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Telephone Number: Fax Number:
E-mail Address:
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2. Agent Information (A signed-and dated copy of the Agent Authorization letter must be attached
if the Agent has signatory authority for the ownedapplieant.)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
IL Project Lformation
Fast Number.
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.
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1. Location
County: ?SfUn ' Nearest Town: Atat-t,rf^if Gt
Subdivision name or rte address (include phase/lot number): 2,GOlrtv60J k-vc, 44-/r-
Directions to site please include road numbers, landmarks, etc. (This is not necessary if an adequate
vicinity map is included): /XC-°&' L L~ Yt' i 7 Y Q Zia&- /P'Id4:V led-
2. Describe the existing land use or condition of the site at the time of thisrapplication: A-Sle'-4
3. Property size (acres): r X "C)"
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4. Nearest body of water (stream/river/soun(/ocean/lake):? I LY
5. Describe the purpose of the proposed work: or a b. ' , zed
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: a? ?'?? = /mod
8.1. Amount of impact (including all clearing, back bill, 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 pool lake level and 50 feet landward to be impacted
(number of trees for instance): Srm cr ?? ./s?,s g yc?s __
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S-Applicant/Agent's Signature bate

(Agent's signature is valid only if an authorization letter from the applicant is provided.)

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