20120482 Ver 1_Shoreline Stabilization_20120515

2 ®120482
The following is an abbreviated application form for those applying for a 401 Water Quality
Certification to unpact FERC (Federal Energy Regulatory Commission) regulated lake shore or
bottom under the U.S Army Corps of Engineers Permit GP330 This Application cannot be used
for wetland or stream unpacts Please provide seven (7) copies of this application and supporting
information as well as a non - refundable application fee to the Division of Water uah of $240 00
for impacts of to lake bottom of less than 1 acre and $570 00 for impacts to
or equal to 1 acre. Do
Applications should be sent to MAY) 5 Z 012
Division of Water Quality 401®versight/Express Review Permitting QENR WmTEN ou,,ii l Y
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Wetland & St ate Branch
1650 Mad Service Center _
Raleigh, NC 27699 -1650
I Applicant Information
Owner /Applicant Information
Name �oi
-
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Mailing Address G 77
s ��.4 4/6' 33 ag I
Telephone Number 336 s s� 3s�r.� Fax Number
E mail Address
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
ul/s J R �C; sAAf Z54
Company Affiliation D c..ir« fame
Mailing Address %yam aua:�- mac / v. //c /JL"o?737 s
Telephone Number 3.31 -a /3 —Sa2 3 Fax Number
E mail Address CL 7°s �'� -rte , / 'vim
H Project Information
Attach a vicinity nap 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

County
Location
(1191i4le -1 1
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)
/cam Ze w�u�9 f� /�'�,r &--I
2 Describe the existing land use or condition of the site at the time of this application
3 Property size (acres) / S
4 Nearest body of water ( stream /nver /sound/ocean/lake) Z, 41e
5 Describe the purpose of the proposed work I- L--i (1, o /?Rn S -one
G (or%l 6tib M I,tv fa &Ia w 44 ervs.aN Dreyaly
6 List the type of equipment to be used to construct the project -T.rGli X
7 Amount of impact (including all excavation backfill np rap, retaining walls etc ) below the
normal pool lake level in square feet or acres
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
8 b Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance)
s 2s Z
Applicant/Agent s Sign ate
(Agent s signature is valid only if an authorization letter from the applicant is provided )