20120527 Ver 1_Shoreline Stabilization_20120530

201 2005 2 7
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
L� Il� 2
Division of Water Quality 401 Oversight/Express Review Permitting LDENR ��OW^ .
1650 Mad Service Center �5 Ll Raleigh, NC 276991650
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I Applicant Information
WATE14 QUHLITY
a � "nwatee Branch
anch
1 Owner/Applicant Information
Name F K IPt tU 1-, t_ 10 " A R %) C
Mailing Address Z 14— L Z 1 LA Q&
.SC-MOUZA to iJc 2-734 -3
Telephone Number (3 3 b) Z3422' 4-1 1� Fax Number (3 3 d ) z 3 4 9 41 4—
E mail Address r'OL n %, t n � 0'r (1 tit) Vyl e L n e t
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
E mail Address
H Project Information
Fax Number
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

I Location
County PC e- S d 0 Nearest Town S C vyI U P-'A
Subdivision name or site address (include phase/lot number) N >✓ (Z i 1Af, E KKA 2►3 0 2 LOT
Directions to site please include road numbers landmarks etc (Tlus is not necessary if an adequate
vicinity map is included) S E E V i G� U i z-� V'h ►A P
2 Describe the existing land use or condition of the site at the time of this application
Property size (acres) t 1 L a o
4 Nearest body of water (stream/nver /sound/ocean/lake) �kl LO L`ck�CG
5 Describe the purpose of the proposed work 1 U S 1khA L A S G A W A L L
(ALOUD- SHL)lk,E L1N E
6 List the type of equipment to be used to construct the protect 5* CA VAS Q F B osCGA
7 Amount of impact (including all excavation backfill np rap retaining walls etc ) below the
normal pool lake level in square feet or acres , eefZo x l o Oc0 S -(
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
Poti F ( S t;A w L L D A.)L J i -'o A&L -Act Cf,%s � ► &J �- e- t�p- RA
fJOQIhAL PooL L <,J C-l.. Pt 9d jC NO2vnA < Poc) L k-O t LL WALT
�STia�G- LVNwOI A- f(>j,, -O-* Sods �) U-)"1 0A W%LL> C3& 2�P�►2��
8b Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance) Oo u & Irb e- t PP tzoy, 's-005
,�2r GYCiSiilJ& I-ALOQ Hkc.0 IAjIL,L (3L-
,5 1261 iz
Applicant/Agent s Signature Date
(Agent s signature is valid only if an authorization letter from the applicant is provided )

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