20120444 Ver 1_Application_20120503

20120444
The following is an abbreviated application form for those applying for a 401 Water Quality
Certffiic a ion to Impact FMC (Federal Energy Regulatory Co ion) regulated lake shore or
bottom under the U S Army Corps of Englaeers Permit GP30 This Application cannot be used
for wetland or stream Impacts Please provide seven (7) copies of this application and supporting
Information as well as a non - refundable application flee to the Division of Wader Quality of tM 00
for Impacts of 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
4
Division of Water Quality 401 OversVOWExpress Review Permitting
1650 Mad Service Center
Raleigh, NC 276991650
Applicant Information
OwnedApplicant
Madmg Address
A_ t .�
Telephone Number 7/"7— may- /` Fax Number
E -meal Address
2 Agent Information (A signed and dated copy of the Agent Authorization letter must be attached
if the Agent has signatory authonty for the owner/apphcaut )
Name
Company Affiliation
Mailmg Address
Telephone Number
E -mail Address.
II. Project Information
Fax Number-
Attach a vicinity neap 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 an-ow The footprints of all buildings impervious sm aces, or other
facilities must be included.

4 { '
t �

I Location
County earest Town ►/l�dl�/G�/
ty /
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) S
2 Describe the existing land use or condition of the site at the time of this application �s�� ' �`' 9/
3 Property size (acres) --5-
4 Nearest body of water (stream/river /son(/ocean/lake) X alre—
5 Describe the purpose of the proposed work `i "7e-
w
6 List the type of equipment to be used to construct the project.
7 Amount of impact (including all excavation, backfill rip rap retaining walls etc ) below the
normal pool lake level in square feet or acres
8 n. Amount of unpact (including all clearing, back fill excavation rip rap retaining walls, etc )
above the normal pool lake level and 50 feet land - in square feet or acres
n - C40
8 b Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for ins e)
A,
Applicant/Waes Signature bate
(Agent s signature is valid only if an authonzation letter from the applicant is provided)

THIS SURVEY IS OF AN EXISTING PARCEL OF LAND
a
BROOKSIOE '
I CERTIFY THAT THIS MAP WAS DRAWN UNDER MY SUPERVISION FROM AN ACTUAL
SURVEY PERFORMED BY ME (DEED DESCRIPTION RECORDED IN BOOK 1363 PG 274)
i
Cq $'
THAT THE BOUNDARIES NOT SURVEYED ARE INDICATED AS DRAWN FROM
INFORMATION IN PLAT BOOK 2 163 THAT THE RATIO OF PRECISION IS 1 10000
AND THAT THIS MAP MEETS THE CAROLINA NTS OF THE STANDARDS OF PRACTICE
FOR LAND SURVEYING IN NORTH CAROLINA (23 CA 66 1 0)
qD *SITE
LAKE
THIS STH DAY OF MARCH, 2012
LERY
PROFESSIONAL LAND SUR EY
ae �.
r
VICINITY MAP
(NOT TO SCALE)�Q
El E ISTINS IRON ROD
NIA HE IRON ROD
K
ELI E ISTIING � PIPE
SFA+
:_ 378
«
`'f�.-
R clip F �4
POpO
s EIP
11-11 s
0
N10
� M
CLAUDE MORGAN
DB 1193 PG 260
OF
RICKY HONEYCUTT
OB 746 PG 356
v
N
a
m
g
0 r 0
s6 u
EIP
0xv ITCH 67
A8M WO
9
L TIL ERY
�u SCALE 1 30
0 A\ 30 15 30 5p
CENTER TOWNSHIP
BUDDY BURKE STANLY COUNTY
NORTH CAROLINA
Scale 1 -30
Date 3/8/2012 IREFERENCE DB 1363 PG 274
Revised Drawn By A M SMITH
ANDREW MICHAEL SMITH PLS L 3784
Job Surveyor 1067 MACK RD ASHEBOM NC 27205
a 9/1, //
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