20121011 Ver 1_401 Application_20121102

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2012101.1
The following is an abbreviated application form for those applying for a 401 Water 'ty
Certification to impact IERC (Federal orgy Regulatory Commission) regulated shore or
bottom under the U.S. Army Corps of ors Permit GP30. This Application be used
for wetland or stream impacts. Please provide seven (7) copies of this application and pportdng
information as well as a non- refhndaMe applieatiQ� lee to the i�ivlsian of Water Q: of X40.00
for impacts of to lake bottom of less than 1 acre and $570.00 for impacts to lake botto of greater
or equal to I acre.
Applications should be sent to:
Division of Water QuAty 401 OveesighVEaprm Review Permitting
1650 Mail Service Center
Raleigh, NC 27609 -1650 � �p
I. Applicant hdormaden 4
1. Owner /Applicant Information .
Name: � .e o � �✓�. � q.t^ 0 ri � �• �'' ! �. r'
Mailing Address:
AZC
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Telephone Number. 7011 --Z V-7--Q 9 7 7 Fax Number.
E-mail Address: __ ra Lki an _rea-1 es t&t-e a n 1 t'
2. Agent Information (A signed and dated copy of the Agent Authorization letter must f attached
if the Agent has signatory authority for the owner /applicant.)
Name:
Company Affiliation: I
Mailing Address:
Telephone Number: Fax Number
E -mail Address:
IL Project Information
Attach a vicinity map clearly showing the location of the property with respect to local lan rake such
as towns, rivers, and roads. Also provide a detailed site plan showing property boundaries
development plans in relation to surrounding properties. Yon may use the dirarn below to a
hand sketch of your project. Also, see the example below for guidance. Both the vicinity � d site
plan must include a scale and north arrow. The footprints of all building- ' F er
facilities must be included. 1 o IIl

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1. Location
County: & 16�«--t`l Nearest Town: '
Subdivision name or site address (include phase4ot number): &K
Directions to site please include road numbers, landmarks, etc, (TMs is not necessary if an r
vicinity map is included):.s,(«sJ��
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2. Describe the existing land use or condition of the site at the time of this application:
3. Property size (acres):
9A c i
4. Nearest body of water (stream/river /sound/oceanflake): A")r _
5. Describe the purpose of the proposed work: o rEmoU i ry
6. last the type of equipment to be used to construct the project: 7;-,�c IL
7. Amount of impact (including all excavation, backfiil, rip rap, retaining walls, etc.) b
normal pool lake level in square feet or acres: q, �f
8.a. Amount of impact (including all clearing, back fill, excavation, rip rap, retaining we
above the normal pool lake level and 50 fat land -ward in square feet or acres:
the
etc.)
8.b. Please describe vegetation above the normal pool lake level and 50 feet landward to, impacted
(number of trees for instance): -e
7//0r c e-
6
4
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Applicant/Agent's Sigkatur+e V Q \,. Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

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