20120867 Ver 1_Application_20120920

2® 1 2 0 8 6 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:
Division of Water Quality 401 Oversight/Express Review Permitting
1650 Mail Service Center a 1
Raleigh, NC 27699 -1650
I. Applicant Information
1.
Owner /Applicant Information
Name:
Mailin€
Telephone Number: Fax Number:
: , . ^ -\ _ I 1
T I . r
e,
E -mail Address:
2. Agent Information ( A signed and dated co py of the g ent 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. Project Information
Fax Number:
SAP o
VGIYfi -
Wetlands
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.

1. Location
County: TjLon Nearest Town:
Subdivision name or site address (include phase/lot number):
i
Directions to site please include road numbers, lan marl s, etc. (Tl
vicinity map is included): AL akc—NO
2. Describe the existing land use or o dition of the site at the time of this application:
3. Property size (acres): 1 LT
4. Nearest body of water (stream/river /sound/ocean/lake): R6M a
5. Describe the purpose of thEna posed wor
�i
1 Eank
6 . List the type of equipment to be use o construct the project: Mwi LIO–O-Va+6V
l excavation, '� `etc. below he
7. Amount of impact (including al backfill, rip rap, retaining a1�s, )
normal pool lake level in square feet or acres:
/� 5 -16,4
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:
T 1�.
8.b. Please describe vegetation above the normal pool lake level and 50 t I dward to be impacted
(number of trees for instance): Q
9 -/y-
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

ConnectGIS Feature Report
Page 1 of 1
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Welcome to the Person County GIS Website. ConnectGIS 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,
ConnectGIS 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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