20120374 Ver 1_Application_20120416

FRED BAIRD BLACKLEY ASLA
LANDSCAPE ARCHITECT
504 SOUTH
SHELBY CAROLINA STREET 2 0 1 2 0 3 7 4
[phone]
1690 Pall S--D-Nlce CQ,��
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For APPROVAL INFORMATION RECORD REQUEST REVIEW COMMENT USE
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""120374
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
C1 provide seven espies of this application and supporting information as well as a
/ non- refundable application fee to the Division of Water Quality of $3,AM for Z` f
impacts of to lake bottom of less than 1 acre and $475 00 for impacts to lake bottom
of greater or equal to 1 acre
Applications should be sent to
Division of Water Quality Wetlands Unit
1650 Mad Service Center
Raleigh, NC 27699 -1650
Applicant Information
Owner /Applicant fo ation
Name VJiIb,�,r` vr *,-
Mailing Address ./
Telephone Number
E mail Address i
Fax Number
TPA
J
2 Agent Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent has signatorythonty for the owner/applicant
)
Name � n �
Company Affiliation
Mailing Address -A��/
Telephone Number Fax Number
E mail Address
II Protect 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
Location V l l kt
County Nearest Town —UML"J
Subdivision name or site address (include phase /lot number) c
Directions to site please include road numbers landmarks etc (This 4 not
necessary if an adequate vicinity map is included)
2 Describe the
application _
3 Property size (acres)
land use or condition of the site at the time of this
4 Nearest body of water (stream/river /sound/ocean/lake) M" ` y`
the,purpgse of, the Rroposed work I `' P req 3 0 L � 5r" v`¢,
6 List the type of equipment �p be used to construct the project
� h i 'Q 1G GuJ ✓R�I�N' 0� � -tn,l ���
7 Amount of impact (including all excavation backfill nprap retaining walls
etc ) below the norm ;l pool lake level in square feet or acres 3 t f D ill y 1"
4 I�W
SJ-
8 a Amount of impact (including all clearing back fill excavation nor p
retaining walls etc ) above the normal pool lake level and 50 feet land ward in
square feet or acres 7 XS,P o Z U 1,-0
L I cam,-► cZ
b Please describe vegetation above the normal pool lake level and 50 feet land
ward to be impacted (number ,oaf trees for instance) � Q, dA r
-/13—
Applicant/Agent's Signature Date
(Agent s signature is valid only if an authorization letter from the applicant is provided )

Lake' (Fall Pond)
Full -P6nd
ho eIIne-
Please approximately sketch the following mformahon on this plan
(please provide dimensions for each item, such as 10 ft x 100 ft)
1) All proposed vegetation clearing (provide dimensions)
Location of rip rap or fill to he placed above the Full Pond elevation
$� Location of rip rap or Hill to be placed below the Full! Pond elevation
4j The loc of any proposed structures such as buildings, retaining
trvailsO , etc
-/6) The location of arty +exc N ior� +fir c �giig below the Full Pond
elevation e�-�^
✓ ti} Location of construction access corridors q,CL.ruj y