20120690 Ver 1_Application_20120716

20 1 20690
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
5 GP30 This Application cannot be used for wetland or stream impacts Please
provide seven opies of this application and supporting information as well as a
non-refundable application fee to the Division of Water Quality of $;AM for
impacts of to lake bottom of less than 1 acre and $475 00 for impacts to lake bottom
of greater or equal to 1 acre
Applications should be sent to
Division of Water Quality Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650
Applicant Information
1 Owner /App
Name _
Mailing
Telephone Number
E mail Address L
1" kK
Fax Number
2 Agent Information (A signed and dated copy of the Agent
must be attached if the Agent has signatory authority for the c
Name
Company Affiliation
Mailing Address
Telephone Number
E mail Address
II Protect Information W"-A/-W
Fax Number
letter
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

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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
1 Location
County Nearest Town
Subdivision name or site address (include phase /lot number) �Jfflv, Rr At&
Directions to site pleas— nclude road numbers landmarks etc (This is not
necessary if an adequate vicinity map is included)
2 Describe the
application _
3
4
5
Property size (acres)' t, 1, i
Nearest body of water ( stream /river /sound/ocean/lake) AA9 1
6 List the type of equipment to be us d to construct the pro ect �a4," �
Vvyy^ IAA AD 91AA4444
7 Amount of impact (including all excavation backfill rip rap xetaVimg walls .
etc ) below the normal poo lake level in square fefeet or acres _ =
nfrkl— '1W -17 ell
8 a Amount of impact (including all clearing back fill excavation rip rap
retaining walls etc) above the nornial pool lake le el and 50 f et 1 nd and r
square feet or, acres
b Please describe vegetation above the normal pool lake level and 50 feet land
ward to be impacted (number of trees for instance) r�Q(�J�
Apphcant/Agen s Signature Date/
(Agent s signature is valid only if an authorization letter from the applicant is provided )

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M Lake (Full Pond)
Full Pond ,-
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horellne
Pleaw approximately sketch the following mfonnataon on this plan
(please provide d%ensions for each item, such as 10 ft x 100 ft)
41) M proposed vegetation eleadng (provide dirnenssons)
2) Location of np rap or fill to be placed above the Full Pond elevation
�J jrS) Location of rip rap or fill to be placed below the Full! Pond elevation
4) The location of any proposed sbuctures such as buildings, retaining
walls, dos, etc
The location of arty excavation or dredging below the Full Pond
elevation
8) Location of construction mess corridors
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FRED BAIRD BLACKLEY ASLA
LANDSCAPE ARCHITECT
504 SOUTH DEKALB STREET
SHELBY NORTH CAROLINA 28150
[phone]
Transmittal
Nis Projects �QA� co
Project No
�!� 6 �`��► Date I
Copies Item Description D
ec L JUL 1 6 2012
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For APPROVAL--& INFORMATION RECORD REQUEST REVIEW COMMENT USE
Remarks
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