20121130 Ver 1_Application_20121220

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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 ('1) 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
Raleigh, NC 27699 -1650
I.
1.
P1
Applicant Information
Owner /Applicant Information
Name:
Mailinl
DEC 2 0 2012
DENR - tATEn OU&ITY I
Telephone Number: 418 0- 4189-a ggZ Fax Number.
E-mail Address:
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. Fax Number:
E-mail Address:
IL 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 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: P,&rA aAl Nearest Town: C'u�✓� �ySh�i� /�'✓
Subdivision name or site address (include phase/lot number): ��✓f�rhP�r _ b V p
Directions to site please include road numbers, landmarks, etc. (This is not necessary if an adequate
vicinity map is included): 70 /cc
Oo Ve 614k 46
LN r-
2. Describe the existing land use or condition of the site at the time of this application:
3. Property size (acres):
4. Nearest body of water (stream/river /sound/ocean/lake):
5. Describe the purpose of the proposed work:
6. List the type of equipment to be used to construct the project: -r, n 466iioe r /fin 2e�
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls, etc.) below the
normal pool lake level in square feet or acres: arAZZ O/—Qn 2 f L e dc.Q 422W
8.a. Amount of impact (including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
above the normal pool l level and 50 feet land -ward in square feet or acres:
�Db 0 ;i
8.b. Please describe vegetation above the normal pool lake level and 50 feet landward to be im acted
(number of trees for instance): A Z04 L
. dW4 l- 3-
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

GI
a
Piea�e appr+oo�fanataly dmbh the 11diouit 8 bd tioion dis plan
(please provide O n lions for each ftm, such as Is R. x 100 It):
1) All Proms vrpatafion dwift wovw dim�ebnsl
A Location of dp rap or fill to be Placed above the Ad Pond elevation
3) Location of dp rap or fill to be pissed below the PO Pond eievalion
4) The location of any proposed Mures arch tie buOdhm roldit
yids, doift etc.
5) Ttm beadon of any excavation or dredging below #w Full Pond
elevation.
6) Location of conelruelllon a©ceee corridors.

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I HIED' CEATIrY THAT THE SUBDIVISION PLAT AS
DEPICTED To ON HAS BEEN WUNTED rINAL APPROVAL TREACY '
PURSUANT r0 THE PERSON Co SUBDIVISION REGUEAr1ON4
TRAIL Is
---------- JJ- l9:cooArf GILLETTE H TREACY PROPOSED «
PLANNING ANO ZONI SANDRA P TREACT
ADMINISTRATOR O B IN, v 371 SO• R/9 Is
ACCESS Na
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(PRIVATE) •1 N ! 8
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LEGEND
W • NAIL FOUND
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IF . IRON FOUNO
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0 MATHEMATICAL
POINT
U IISS SI6NED. SEALED AND DATED, rNl1 IS A
OR CONINMY PLAT, NDT TOR RECORDATION, SALES
OR corlrErANCEs
assocw7�ES�, PA
PROfESS10NAL (AND SURVEYORS ••
212 S LAMAR SIREET - PO BOX 1266
ROXBORO NORTH GROUNA 27377
(336) 599 -8712
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200 12 1•
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STATE Or MORIN CAROLINA
COL«UveASGN
OR PLAY T CpRCY, RI rY IHAT RE MAP
OR
MrIXED PLAT TO T11 IONIC" L THIS CERTIr(CAR IS
FOR AECOROIND All STANfORr NEWIR[lENi7
REVIVI
_E'TO --_ wrc rob
fR OFFICER, -
PLAT OF SURVEY
CANTERBERRY COVE
CUNNINGHAM TWP., PERSON CO., N.C.
NOVEMBER 2008, HAMLETT - JENNINGS d ASSOCIATES
212 S. LAMAR STREET, ROXBORO, N.C.
JOHN J. JENNINGS L -3052
M
aw MIGHT IKA • b ll
OWNER: GILLETTE N. TREACY
SANDRA P. TREACY
GILLETTE x TREACT
SANDRA P TREACr
O B IU. P 371
TREACY TRAIL
PROPOSED
SO- R/W
ACCESS
$ IPRIY�AYENT
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CONTROL
420•
CONTOUR
MOUTH CAROLINA PERSON COMV
1. __�L9M_1._1LBtl1o6i CENT"W THAT THIS
SIRYEr CREATES A SUBOIYIS /ON O/ lAND .THATK
__lE669TL. COUNTY AIINESS MY HAND AND SEAL THIS
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DATA TABLES
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