20120469 Ver 1_Shoreline Stabilization_20120510

20' 2046 9
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 Z
Division of Water Quality 401 Oversight/Express Review Permitting
1650 Mad Service Center p
Raleigh, NC 27699 1650 D
1 Applicant Information P✓igY ly 2012
1 Owner /Applicant Information we NR WAT�f? Of ITy
�
Name !:f °5 k t o Warea Brae
Mailing Address 6�6D
�b
Telephone Number 91b - 4.19 I'M Fax Number
E mail Address
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
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 protect 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 1'l/tt i��� o m� Nearest Town YYN- C, � e",-C\
Subdivision name or site address (include phase/lot number)
Directions to site please include road numbers landmarks etc (Thus is not necessary if an adequate
vicinity map is included)
2 Describe the existing land use or condition of the site at the time of this application
3 Property size (acres) :w '
4 Nearest body of water (stream/river /sound/ocean/lake)
5 Describe the purpose of the proposed work R��ga �Q LO-M,
'h
6 List the type of equipment to be used to construct the project hQrt L -b015
7 Amount of impact (including all excavation backiill no rap retaining walls etc ) below the
normal pool lake level in square feet or acres 6 Y X 31 - _11 vie Y,
T `- �rc ware wI r � r�0o t-,\ �cor�� � toxt
t a 1 A o c 1 5 r K
8a Amount of impact (including all clearing back fill excavation rip rap retaining walls etc )
above the normal pool lake level and 50 feet land ward in square feet or acres
nv ne-
8 b Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance) 9 lb 10,
Applicant/Agent s Signature Date
(Agent s signature is valid only if an authorization letter from the applicant is provided )

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Lake Tillery Property Owner:
Frances Brock (formerly Frances Moore)
660 Fairwav Shores Road -
Mt. Gilead NC 27306
(910) 439 -4449