20120414 Ver 1_Application_20120425

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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 y ��
Division of Water Quality 401 Oversight/Express Review Pernutting
1650 Mail Service Center DRaleigh, NC 27699 1650 U
I Applicant Information
APR ") 2012
1 Owner /Applicant Information I
oENR WATER a l
Wetlands & St ►mwate Branch
Name U IM ,� -- -
Mailing Address -3Z- (,e� 0
`V 1 L 4-1 Lti Z-% 30 �n
Telephone Number il7Dq Fax Number
E mail Address —f'-5C.t LV, k-J>C PtOL eC"
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 PO 6 er� ( (a kc,1-
Company Affiliation Srdc C04,.C�pq
Mailing Address (05'79 Wi IIoW Oa K 8,4 Norwood, A[C d-W191
Telephone Number q0u-q 3g -0 61 to Fax Number
E mail Address 1:6 Id q u ate. JJAM"aM aet
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

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1 Location
County M o rw l !a g� Nearest Town
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) qWW VI/3 -1 fa 9. d era P", ek - o U o o dO "W
StkbdtatsIca%r
2 Describe the existing land use or condition of the site at the time of this applications
3 Property size (acres) t!y G, G RC—S,
4 Nearest body of water ( stream /nver /sound/ocean/lake) 1, A -ke :rI � ��2u,
5 Describe the purpose of the proposed work Rt M oa E V w Jew P%� N crcl co aR&VU-
S *Ar✓a /1 C—, le 0' lac.AE A✓. AA I✓t Am +eaI a %s e.
Skok.hm6 Sf-a k 1. -4-, ew
6 List the type of equipment to be used to construct the project —L . u 01C , o b eJ-
7 Amount of impact (including all excavation backfill np rap retaining walls etc ) below the
normal pool lake level in square feet or acres 7 S Y 3 Z 2 S'' s E4
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
�jrcE �IQef✓)w4 1 7is r /V 7.50 /tV-
8 b Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance) 3 6-r P c p e u e a
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Ap li ant/Agent s Sig ture Date
(Agen s signature is val n if an authorization letter from the applicant is provided )

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North Carohna Department of Cultural Resources
State Historic Preservation Office
Beverly Eaves Perdue Governor Ramona M Bartos Administrator
Linda A Carlisle Secretary
Jeffrey J Crow Deputy Secretary
April 13 2012
Robert Gallagher
Lakeside Contractors
10579 Willow Oak Road
Norwood NC 28128
Office of Archives and History
Division of Historical Resources
David Brook, Director
Re Jun Humphrey, Soil Disturbance, 406 Fiddlers Ghost Circle Mt. Gilead, Lake Tillery
Montgomery County, ER 12 0504
Dear Mr Gallagher
Thank you for your application of March 29 2012 concerning the above project
We have conducted a review of the project and are aware of no historic resources which would be affected by
the project Therefore we have no comment on the project as proposed
The above comments are made pursuant to Section 106 of the National Historic Preservation Act and the
Advisory Council on Hnstonc Preservation s Regulations for Compliance with Section 106 codified at 36 CFR
Part 800
Thank you for your cooperation and consideration If you have questions concerning the above comment,
please contact Renee Gledhill Earley environmental review coordinator at 919 807 6579 In all future
communication concerning this project, please cite the above referenced tracking number
Sincerely
601(Ramona. M Bartos
F�

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