20120441 Ver 1_Shoreline Stabilization_20120502

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 seven (7) 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 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
Division of Water Quality 401 Oversight/Express Review Permitting
1650 Mail Service Center
Raleigh, NC 27699 1650
Applicant Information
Owner /Applicant Information
201 2044 1
Name 6aq L2. -v U 0, Y-n 6 MIN fl J 6tt-'l' `� `�'((n Co x li n
Mailing Address l LP 71 0)'y D �
6-vun5 m f NC 27 -Iy
Telephone Number 3 A 15 J q 27,,� �- Fax Number
E mail Address Cl Q U % '' C t - / VDU — C') e r1 +a l C_ O ►l')
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 o
Company Affiliation Z
a -<
Mailing Address V
Telephone Number Fax Number ND
E mail Address c Z r�
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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I Location
County Pcr--,or)
Nearest Town
Subdivision name or site address (include phase/lot number)
Directions to site please include road numbers landmarks etc
vicinity map is included)
x;33 51
rn ci re, �.
(This is not necessary if an adequate
2 Describe the existing land use or condition of the site at the time of this application
3 Property size (acres) 1 4 A f r-j
4 Nearest body of water (stream/nver /sound/oceanAake) L k C 0 L-01
5 Descnbe the purpose of the proposed work `JVP d raI ncg
6 List the type of equipment to be used to construct the project 1 �e Y I-S 1 o O-e
7 Amount of impact (including all excavation backfSill pp rap retaining walls etc ) below the
normal pool lake level in square feet or acres / 5
8 a Amount of impact (including all clearing back fill excavation np rap retaining walls etc )
above the normal pool lake le d 50 feet land ward in square feet or acres
S
8 b Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance) 01
Applicant/Agent s Si nature Date
(Agent s signature is valid only if an authorization letter from the applicant is provided )

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