20130029 Ver 1_Application_20130110

JAN -07 -2013 08:14 City of Kings MT PLANNING
704 734 4490 P.005
20130029
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 C.S. Army Corps of Engineers permit GP30. This AppOcation cannot be used
for wetland or stream impacts. Please provide seven M 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 I 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 E l
Raleigh, NC 27699 -1650
a _
I• Applicant Information
Owner /Applicant information
Name: ow e- I 1
Mailing Address: 7.5 Z7j 0'a K G e= d
e I b u tj C
Telephone Number: d oA) 44 Fax Number.
E -mail Address:
2. Agent Information (A signed and dated copy of the Agent Authorisation 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:
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
hand sketch of your project Also, see the example below for guidance. Both the vici
plan must include a scale and north arrow. The footprints of all buildings, impel "
facilities must be included.
below to make a

1. l,�_�
`�tOn
County; l._Lv t;
Subdivision �'� t`� O
name or site Nearest Town:
Aitections to site (include phase /lot
please include road 'umbers, landmarks, etc.
��):
vici nity Map is included);
704 734 4400
C .
(Th's is not recess
ary'fan adequate
1
2.
Dwribe the existing land use of co
3. doe
4 o�y size (acres): p • nd, ' of the site at the time of
aarest body of pater this application:
S. tk I sttramMverlsound/oc
�nibe puffte of aka): o�
proposed work: 1 �.►5 � ''s '�, 4k r=
L p A lam' K3 Z
1 C— 9Z_
6' List the type of
7. Amount of'm equipment to be used to co
Pact (including all excav nsauct the proRect: �'� , - `+o
normal pool lake level in ation, backfill, rip rap, v - �
squaw feet or acres; p tainu►8 walls
8.a. a oG ' Q , etc.) below the
ARtoW1t of V11 F� .
Pact (tnclu
above the not7nal ding all cleating► back
QUO Poo17 a level and fill, excavation
SO fat land -ward in s9i . retaining walls, etc.) or acres:
8•b• Please
describe vegetation
(number of above the normal pool fake level
arcs for instance): and SO feet land to be impacted
(Agent -s si *-me s 018natft
gna(ut+e is valid only if an authorization Q A,'
zahon letter from Date
the applicant is provided.)
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