20110693 Ver 1_Application_20110725

? 20110893
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 OversighVExpress Review Permitting
1650 Mail Service Center
Raleigh, NC 27699-1650
1. Applicant Information
1. Owner/Applicant Information
Na ee:
Mailina Address:
RE-0 ENED
OF WAT ER QUALITY
t? ttr,_ra_
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 Affiliat
z ?.

M

Mailing Address. '
16q;n, 4 IQn JS 4A/. iL C, 2-R-0 -3 -7
Telephone Num N . '7 - / y-L, -3 Fax Number:
E-mail Address:
IL 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
Telephone Number: ('ate) ?3 - Fax Number: 5A-ryie.
E-mail Address: _
G-f m w, ral L°? C- n z o C3 n
J

4 F
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- Nearest Town:
C_O!:2? i3
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 map is included):
- 7 i"n ? ?fi ST i rr?s
G L.J?Sr= Z?L? Lt
2. Describe the existing land use or condition of the site at the time of this
application:
3. Property size (acres):
7zc, 4
4. Nearest body of water (stream/river/sound/ocean/lake):
//Ir- Zo ?-(>e),d

7`61,
fr
v
q
N
1
q r
N
:3
v
O
n goo?+.?,?
0
PS Q i N ? Cl
3N? ?.?°o
4
??;?4?oC cr
o 2
{ y D
N i
CA Nqo 4cn
O
? ? ? N 4 N ti
? N O
' 1 °a 4 o° s
N w O
4
,°?3ga?a?'T
? n -? 4 ci q N
4 ?1 i C1 a O C
j j O N Q
g o p a} r
N ^w ? ? i '
v o 4
0
ti o
O
u`a4'?i+???1SV6iQ89u4ey Ap'?i
r
+" .fy"" f _ /? O Ay
?•
r Cz, C? ? y
L?Pr? rn n
sj s
1
}
?wr --
5
'L
v
D o
CID m
C
OD
G ?
U
Ch
?b
u
D
f
SS7
13 ?
A ..Rj
0
v
I} •
m
m
0
m
i
z
m
1

b
Q!
"y
Z ; +
t?
Jun

w
s't
L', FFpEh..
2 b
'c
?*t b

i
G?
ld

y
c
a ?
? ? I

c
C

n,

?V
V

v