20120205 Ver 1_Application_20120224

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2 ®120205
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 ;� 2A
C 1fJ
D1VLSlon of Water Quality 401 Oversight/Express Review Permitting
1650 Mail Service Center
Raleigh, NC 27699 1650
I Applicant Information �2
1 Owner /Applicant Information FEB 2 4 2012
DENR WATER QUALITY
WETLANDS AND STORMWATE BRANCH
Name 1 N&MAS 1A.S1 _4,.1 & J U iJ
Mailing Address
Telephone Number
E mail Address
W, 0 7' ON 70- 3 r
Z04 !a 7 (a CQ q Fax Number
vm x-, e Kit e- k) u.S m -4-)-1 X14. ,
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 /If IA
Company Affiliation
Mailing Address
Telephone Number Fax Number
E mail Address
II 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

I Location
County act UL , Nearest Town O a a LW la
Subdivision name or site address (include phase/lot number) i to 2i 5 rA L —y i i,-J D L,
Directions to site please include road numbers landmarks etc (Thus is not necessary if an adequate
vicinity map is included) CT" W COW L060 r—O 1-U-7— 6A
2 Describe the existing land use or condition of the site at the time of this application
3 Property size (acres) 64 SAP a S
4 Nearest body of water (stream/nver /sound/ocean/lake) LA KL 1 014 1- ili_
5 Describe the purpose of the proposed work !S W &12A LI-J E �o c_a tat `TI Oyl
6 List the type of equipment to be used to construct the project TkA Ma
7 Amount of impact (including all excavation backfill np rap retaining walls etc ) below the
normal pool lake level in square feet or acres ZZ.0 i.f Y �` o� -
�&/-
8a 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
Z7-,o i_L x 3 / + ZZo 4->: x 16 1 - Z -(vO 5A
Z �LzO p,n
8 b Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance) ti S ru f C, + p4 a £ X51 N om, U to . ,-O 11c-11
(Agent s signature is valid only if an authorization letter from the applicant is provided )

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16215 Fallview Drive, Charlotte, NC - Google Maps
G Address 16215 Faliview Dr
o Charlotte, NC 28278
Get Google Maps on your phone
49 Textthe word "GMAPSto466453
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