20120715 Ver 1_Application_20120726

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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 $570 00 for impacts to lake bottom of greater
or equal to 1 acre
Applications should be sent to
Division of Water Quality 401 Oversight/Express Review Permitting
1650 Mad Service Center
Raleigh, NC 27699 -1650
Applicant Information
Owner /Applicant Information
Name
aoY)OAa M t c lnael DAV 15
Mailing Address 2a ( Zane TV-0't t
Leas burn , N G 212.Q t
Telephone Number 434 250- Li243 Fax Number
E mail Address S&VIs f2 MAI dips k12 VQ U$
(TDAID
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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
II Protect 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 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

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Location
County Plsby Nearest Town Roy &M Odl. �•
Subdivision name or site address (include phasellot number) %/ "WL
Directions to site please include road numbers landmarks etc (This is not necessary if an adequate
vicinity map is included) .flee- aftAc,W MA,P
2 Describe the existing land use or condition of the site at the time of this application MlJav!''hi
3 Property size (acres) O 53 at,rti
4 Nearest body of water (stream/nver /sound/ocean/lake)
5 Describe the purpose of the proposed work (,AAA Aa Wr f a rJA)
6 List the type of equipment to be used to construct the project BA ddt- , I.R CAM frAy,
7 Amount of impact (including all excavation backfill np rap retaining walls etc ) below the
normal pool lake level in square feet or acres t6 l Xrr,
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 to 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) ONE ck&
Applicant/Agent s Signature Date 0 �
(Agent s signature is valid only if an authorization letter from the applicant is provided )

Pleas appronnudely sketch the faftemg sfforrnation an tins plan
tease provide egmensions for each Item, SUCK as 10 ft x Joe ft)
1 j M proposed vegetation awing (provtde dintensions)
Z) Location of rip rap or fill to he placed above the RA Pond slsvMlon
3) Location of rip rap or fill to be placed below the Fug Rend elevation
4,1 The location of mW proposed structures such as buildings. retaining
wags, docks, etc
6) The location of any excavation or dredging below the Full Pond
elevation
8) Location of construcOon a0cess corridors
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