20110860 Ver 1_Application_20110919

The following is an abbreviated application form for those
Certification to impact FERC (Federal Energy R ?p for a 401 Water Quality
bottom under the U,,& Army Corps W6tory won) regulated lake shore or
FAMOneen Permit GP30 Phis Application cannot be used
for wetland or stream
impact& Please
inf'onnation as well as a _ ?PTOVide seven (7) copies of t? appUcation and
supporting
o=r impacts of to lake bottom of >ess than lp? Xfee to the 570 0D for of Water Quality of $240.0
dual to 1 acre, llnpacts to lake bottom of greater
Applications should be sent to..
1 1 0 8 6 0
0
Division of Wes. Quality
401 Oversight/Express Review Permitting
1650 Mao Service
Center
Raleigh, NC 27699.1650
L Appliut Information
1. Owner/Applicant Information Name: Lagacy C vas u-c,
Mailing Address: l3a?C 113
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Telephone Number: X36 S ?j D 3 Zak Fax Number S R 7 Z 18
E-mail Address: C b ? ? C -- bU i /d,k
2 Agent Information (A signed and datoxl -
if the Agent has signatory copy of the Agent Authorization letter must be attached
authority for the owner/applicant.)
Name: E .?yS 'ate D
Company Affiliation:
Mai&g Address: 1 9 2011
Telephone Number. DEAR_ 4yq?RQ
Farr Number NfkQ Uaun
E-mail Address:
II. Project Information
Attach a vicinity map clearly showing the location of the property with
to local landmarks such
as towns, rivers, and roads. Also provide a detailed site respect
development plans in relation to surrounding pupaties. you plan showing Property boundaries and
hand sketch of your proact. Also example below fp guidyanuse the aVam ce_ below to make a
Plan must include a scale and north arrow. The footprints Both the vicinity map and site
facilities must be included. of all buildings, impervious surfaces, or other
I • Location
County: I?e Y5o?1
Nearest Town: Sib a?
Subdivision name or site address (include Phase/lot number): LvT Zo
Directions to site please include mad numbers, landmarks, etc. r'his is r
vicinity map is included): Fr OYv, Q'Y' 61)(D ' not necessary if an adequate
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Describe the existing land use or condition of the site at the time of this application: 622sicFs....4.4
3. Property size (acres): O I AC 0 tom, I t-o W9 LOT
4• Nearest body of water (stream/river/sound/ocean/lake): I w l?
5. Describe the purpose of the proposed work: T_v,5}-a I 1 2. p Q- o-
w ? ?j" C_ ?-p hn t mil' o ; o
h• List the type of equipment to be used to construct the project: 51? ? .D STS Lt p
7. Amount of impact (including all excavation backfill, rip retaining normal pool lake level in square feet or acres: g walls, etc.) below the
(bo' X (C ' = q 6o Si=
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:
l lit' x IS - Z 4n n ,,
8-b. Plcasc describe vegetation above the normal pool lake level and 50 feet Iandward to be irn ed
(number of trees for instance). pact
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Applicant/Agent's Signature T
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
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