20120159 Ver 1_Shoreline Stabilization_20120214

20120 159
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
2
Applicant Information
Owner /Applicant Information
Name
(Jr �TID
Mailing Address
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Telephone Number �a, �� A� Fax Number Q/ 6 Y_ ys y f6 g
E mail Address 191 14 a ru S& N
ao/ c VVVt
Agent Information (A signed and dated copy of the Agent Authorization letter must be attached
if the Agent has signatory authority for the owner /apphcant)
Name .� A-PA
Company Affiliation
Mailing Address
Telephone Number
E -mail Address
H Protect Information
FES
OFNR
Fax Number .1 " "M 1-ERBRUo,
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

I Location
County _LJ J� "��$n Nearest Town
Subdivision name or site address (include phase/lot number) 0) �� ��f �4 -�J MI
Directions to site please include road numbers landmarks etc (This is not necessary if an adequate
vicinity map is included) Y �a d Late T I./e N lei -hT
ON �q -p AiQ� J C 7G1/ell� OP 6O TA/D ,�/ti "Ak. Ad
A a 9 ftV tl !�'1 1E o �� t
2 Describe the existing land use or condition of the site at the time of this application
3 Property size (acres) /rms— oN / d /a c /IK- S
4 Nearest body of water (stream/nver /sound/ocean/lake)
5 Describe the purpose of the proposed work bTA _S a / I hl 6906)0,A)
6 List the type of equipment to be used to construct the project Y6A WA
7 Amount of impact (including all excavation backfill np rap retaining walls etc ) below the
normal pool lake level in square feet or acres / Pd Fe> E.1' p
Ca t'+bu iz UJ LIL qJ� �1 1J t�- 41." 49-/ 00,f
8 a Amount of impact (including all clearing back fill excavation np rap retaining walls etc )
above the normal pool lake level and 50 feet land ward in square feet or acres
15 60 so kt
8 b Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance) UN 1D,C/Z 1s20 , , A /010
A VjAQ rEVE
I2
Applicant/Agent s Signature Dal/ I
(Agent's signature is valid only if an authorization letter from the applicant is provided )