20121022 Ver 1_Application_20121106

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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 five (5) 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 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
I• Applicant Information
1 • Owner /Applicant Information
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Name: RA
Mailing Address:
Telephone Number:0�8) p�g 3"1(r, Fax Number:
E -mail Address:
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: - e-n ()rn ni nn
Company Affiliation:
Mailing Address: L/i
Telephone Number: Fax Number:
E -mail Address: 10h n ir} r,ri crn !v,nr ii if ,
II. Project 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-la
hand sketch of your project. Also, see the example below for guidance. BothAhe-
plan must include a scale and north arrow. The footprints of all buildin ite
facilities must be included. ' L ther

1. Location
County: Nearest Town: _7UC�C;QSepee,
Subdivision name or site address (include phase/lot number): CI I N i Q h+i nraaAe Ln
V
Directions to site please include road numbers, landmarks, etc. (This is not necessary if an adequate
vicinity map is included): Ercm 17n of 107 aM 95?1 prac ed !;o, A
..OdonG &Vl d tad• frr O- Wrnrirr l , y smiles 17)akz c.�r�h�- hrrv� an
Tuc = o it mile-
pfQPev-+J s t'he IaS+ house on road a.5 per a.++ac w C XS i Ma e,:S,
2. Describe the existing land use or condition of the site at the time of this application: t)wd- in atr eat
�•�� 3Stor hocase.
3. Property size (acres): ©, y
4. Nearest body of water (stream/river /sound /ocean/lake): Beets 1_Gt IC.2�
5. Describe the purpose of the proposed work: ! I5mro k t oe 5'n �►1N1
a4? St4+dl S4vae r
6. List the type of equipment to be used to construct the project: � S Y n r-
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls, etc.) below the
normal pool lake level in square feet or acres: 2A 1_ n. •}- (a') �- a of Ln.f .
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:
8.b. Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance): 5;IMI I FxCO\J01iO'n &QPi_�y1en f Lot
`KAo c c �°O Ire:. e ,^. - — r _ __ . _ i _ _ in'1 .%_ I.
Ca.l I Per 04
E
��U`;W -�4t U -
.1 ) dee idueds `trees ((
C-V,4U M
IG
i= au r 11
les a incl I
3U / 2..0 t--Z,
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
LoI1k neeA -to be, rexovecl cOon9`the, pa.1) +0 a.11OW a�'eess.
a- t iffier lay e, cal exist +Tees uDI l I ooi be i m "W
0 5 D P

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT N0. PLAN NO. PARCEL ID: —1 159(o - 7a -3t -1 7
STREET ADDRESS:
Please print:
Property Owner:
Property Owner: (]l (1ne J0 �-
The undersigned, registered property owners of the above noted property, do hereby authorize
en 6 f cLn I in A � of Gr in SC 25, Unc.
(Contractor / Agent) (Name of consulting firmy
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature
Date:
Authorized Signature
Date: 1 la l ) a

=R -
TUCKAWAY ROAD
�+s TUCKASEC$ NC
r a
e/31/a
a
EXISTING GRAVEL DRIVE
Waslaawsm mil
EXISTING GRAVFI PATH (PROP05ED ACCE55)
PROPOSED RIP RAP/ BOULDER WALL (2)
EXISTTG DOCK

A
Setzer
This map is prepared for inventory of real property within Jackson County. It is compiled from recorded deeds, plats, and public data
records. Users of this map are hereby notified that the aforementioned public information sources should be consulted for verification.
Jackson County or any County representative assumes no legal responsibility for the contents of this map.
c.
Printed -Oct 15, 2012

Setzer
This map is prepared for inventory of real property within Jackson County. It is compiled from recorded deeds, plats, and public data
ti records. Users of this map are hereby notified that the aforementioned public information sources should be consulted for verification.
Jackson County or any County representative assumes no legal responsibility for the contents of this map.
Printed:Oct 15, 2012