20130053 Ver 1_401 Application_20130122

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20130053
The followb g is an abbreviated application form for those applying for a 401 Walla Quality
Cerii� cation to impact MRC (Federal Energy Regulatory Comnmmion) regulated lake shore or
bottom under the U.B. Army Corps of zn&eecs Perm# GM. This Application cannot be used
for wetland or stream impacts. Please provide seven M copies of this application and supporting
information as wen as a non - refundable application fee to the Division of Water Quality of $240.40
for impacts of to lake bottom of less than 1 acre and $570.80 for impacts to lake bottom of greater
or equal to 1 acre.
APPlicaiiioos should be sent to:
Division of water Quality 401 OversighdExpress Review Permitting
1650 Mail service Center
Ralogh, NC 27699 -1650
r
L Applicant J'T �J
1. OwnedApplicant Ir&mnation
Name•
Mailing Address:
Telephone Number. 9022 —e�lr Fax Number:
E-mail Address. _1 15 03 ��i o�, �• � C
r ' r•
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be attached
if the Agent has signatory authority for the ownedapplicant.)
Name:
Company Affiliation:. a S- Z 17
Mailing Address: 1 `�
Telephone Number. Fax Number: N u 2',"13
E-mail Address:
II. Project information
Attach a vicinity amp 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 bmmdaries and
development plans m relation to sm=mdmg 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.

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1. Location
County: Nearest Town: Ala'rm/avz�
Subdivision name or site address (include phase/lot number):
Directions to site please include road numbers, landmarks, etc. (This is not necessary if an adequate
vicinity map is included):
2. Describe the existing land use or condition of the site at the time of this apP lication: /s.
3. Property size (acres):
4. Nearest body of water (stream/river /sound/ocean/lake):
5. Describe the purpose of the
poposed work:
b. List the type of equipment to be used to construct the projecx: Tgc
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls, etc.) below the
normal pool lake level in square feet or acres: o?GO -®-,
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 lan(�-ward ip square feet or Beres
8.b. Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance):
(Agent's
is valid
bate
if an authorization letter from the applicant is provided)

12/17/2012 11:32
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