20120587 Ver 1_Application_20120613

Jimmy Lewis & Sons Grading & Septic Inc
1024 Henry Street
Roxboro NC 27573
Phone [phone] Fax [phone]
June 12 2012
Division of Water Quality
1650 Mail Service Center
Raleigh NC 27699 1650
Attn Ian McMillian
Re Application for Darya Oskolkova Permit
1731 & 1733 Concord Church Road Roxboro NO
Dear Mr McMillian
2 ®120587
Per our conversation on June 12 2012 that the homeowner owns both properties and the work
will be continuous since the lots are adjacent You authorized that we could fill out one
application and send only one check for the amount of $240 00
If you have any questions please do not hesitate to give me a call
Smc ly
Claire E Ferris
Jimmy Lewis & Sons
".,Z
JUN 1 3 1011

i
Y

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 Informnation
Owner /Applicant Information
Name
Mailing Address
Telephone Number
E mail Address
1731 Concord Church Road
Roxboro. NC 27574 1 1 1
336 -598 -5870 Fax Number
mvxcommerce&embargrnail com
W-
. Ee Branch
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 Jimmy Lewis & Sons Grading & Septic, Inc
Company Affiliation
Mailing Address
Telephone Number
E mail Address
II Project Information
1024 Henry Street Roxboro. NC 27573
336 - 599 -1806 Fax Number 336-5q.9-9890
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 Person
Nearest Town Roxboro, NC
Subdivision name or site address (include phase/lot number) 1731 & 1733 Concord Church Road
Directions to site please include road numbers landmarks etc (This is not necessary if an adequate
vicinity map is included) 1731 Concord Church Road Roxboro, NC 27574
1733 Concord Church Road Roxboro, NC 27574
2 Describe the existing land use or condition of the site at the time of this application
3 Property size (acres) 127 Acres
4 Nearest body of water (stream/nver /sound/ocean/lake) Hyco Lake
5 Describe the purpose of the proposed work Install rip -rap and fabric for the shoreline
6 List the type of equipment to be used to construct the protect Excavator
7 Amount of impact (including all excavation backfill rip rap retaining walls etc ) below the
normal pool lake Ievel in square feet or acres N/A
8 a 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
4,000 square feet
8 b Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance) Scrub under growth
�// Z Z e�Z
Applicant/Agent's Signature Date
(Agent s signature is valid only if an authorization letter from the applicant is provided )

Pik` &
`'Jo a 4.e cJl
Please approximately sketch the folilwamg ffforrnabon on Erns plan
lease provide ditmmsions for each Item, such as 110 ft x IN ft)
1) M proposed vegetation clearing (provide dimensions)
2) Lotion of rip rap or fill to be planed above the RM Pond elevation
3) Location of rip rap or fill to be placed below the Fug Pond elevation
4) The location of ow proposed s0ructums such as buildings. retaining
wAsP dons, etc
6) The location of any excavation or wedging below tine Full Pond
elevation
6} Location of construction $ocess corridors

Please approximately sketch the following udbrvnabon on this plan
{please provide d1knenslons for each item, such as 10 ft x IN ft)
1) AA proposed vegetation clearing (provide dimensions)
2) Location of rip rap or fill to be placed above the Fina Pend elevation
3) Location of rip rap or fill to be placed below the FtA Pond elevation
4) The location of any proposed shuctum such as buildings, retaining
walls, docks, etc
6) The location of any excavation or dredging below the Full Pond
elevation
6) Location of construction access corridors

ConnectGIS Feature Report
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xWelcome to the Person County GIS Website ConnectGlS has been prepared for the inventory of real property found within Person County and is
compiled from recorded deeds plats and other public records Users of GIS system are notified that the aforementioned public information sources
should be consulted for verification of the information in this system Person County Mobile 311 ConnectGlS assume no legal responsibility for the
information in this system Grid is based on the NC state plane coordinate system 1983 NAD
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ConnectGIS Feature Report
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OBJECTID
1369
RECN
1387
PIN
9978 03 10 5296 000
CALCACRE
1 19248080574
ZIP
27574
NAME
CHIZHIKOV MIKHAIL & DARYA OSKO
NAME2
BILLINGADD
1731 CONCORD CHURCH RD
CITY STATE
ROXBORO NC
TAXMAP
A16 97
DESCR
STONEGATE /LT5 /H &L
ACRE
127
DEEDBOOK
328
DEEDPAGE
1
SALEVALUE
210000
LANDVALUE
130405
BLDGVALUE
270007
PLAT
SITUSADDR ICONCORD
CH RD 1731
CURRENTVAL
1420961
CITY
ICOUNTY
SALEDATE
5/18/2001
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ConnectGIS Feature Report Page 1 of 1
http: / /gis.personcounty. net / connectgis_ v6 /DownloadFile .ashx ?i= _ags_map5d6ee663 f39c48... 6/4/2012