20130332 Ver 1_Application_20130401

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20130332
The fogoWgg IS an abbreviated a
Certi6cadoa to application form for those
bottom under Impact MRC (Federal Rnera Regulato 3'mg fora 401 �PVater
the US. Army Co G on) re shore or
for wetland or streaat �E Permit GP30. This q gabted hike
f�ormaflon 8 "a Please provide seven fee copies PPlicatioa cannot be used
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well as a °0pi'�ndable application fee to the DI a1�pDcadon and support
Impacts of to lake bottom of less than i acre and vision of Water Quality Of $240.00
or equal to I acre, 5570.00 for hnpacts to lake bottom of greater
Application should be sent to:
Division er Quality 401 Ov
meterPress Review Permitting
Rale+, NC 27699.I650
I• Applicant Information
1, Owner /Applicant Information
Name: Ime L�TCN6
MWhg Address: (In L1
Telephone Number:
E-mail Address:
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Agent Information (A signed and dated copy of the Agent Authorization
if the Agent has signatory authority for the owner /applicant.)
letter must be attached
Name:
ComPUY Affiliation: � !
Mailing Address: w
Telephone Number: R ' 1 2013
Fax Number:
E-mail Address:
1L Project hformation
Attach a vicinity map clearly showing the location of the
as towns, rivers, and roads. Also provide a detailed site plan Showing ro with ttespect to local landma such
development plans in relation to surrounding P OPeRY boundaries and
hand sketch of your project, Also. see the example be o or may use, » the Both diagram
vicinity to make a
Plan must include a scale and north arrow. Tl� footprints b all idance im map and site
facilities must be included, buildings, Pervious surfaces, or other

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1. Location
County: <� t rr U (._� {� (� Newt Town:
Subdivision name or site address (include phasenot number): b d COO
Directions to site please include road numbers, landmarks, etc. (This is not necessary _ l
vicinity map is included): if adequate
2. Describe the existing land use or condition of the site at the time of this application:
3. Property size (acres): 0.44b
4. Nearest body of water (sgeam/dver /sound/oceaMake): _ Mpoc L,
5. Describe the purpose of the proposed work:
A, P-
6. List the type of equipment to be used to construct the Pr'oJ ect.
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7. Amount of impact (including aU excavation, backfill
. rip rap. retaining walls, etc.) below the
normal pool lake level in square feet or acres:
8 -a- Amount of impact (including all clearing, back fill, excavation rip
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above the normal pool lake level and 50 feet land -ward in
4r< square re g walls, etc.)
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8.b. Please describe vegetation above the normal
pool lake level and 50 feet landward to be impacted
(number of trees for instance): �� -� s o F (2" OC2- �oQ�
�%l,11197
signature is valid only if an authorization letter from the applicant is provided)

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DATE „1- tWFLICATION:
--W-T 1C
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APPLICANT(S):
OWNERS):
OWNER(S) MAILING ADDRESS:
r:
OWNER(S) SIGNATURE(S): <:
S ,�
ADDRESS OF LAKE PROPERTY:
SUBDIVISION NAME:
ot�6rxo/
TAX MAP: - !'L
BLOCK: `L
CURRENT LEASE #: - -, LOT: J,
TELEPHONE # FOR oa PIT
CONTACT: #.
70/0 S'�w (HOME)
WIDTH OF LOT AT SHORELINE: RELINE: i
NAME AND PHONE # OF ENGINEER OR
ARCHITECT:
P. E, 70 f m
NAME AND PHONE # OF CONTRACTOR:�� c
-- - x.1.1 c�cw 10N OF SHORELINE:
SEE ATTACFICD PLANS:
('40 APPLICATION CAN BE REVIEWED µ11'HOUT PLANS MADE IN ACCORDANCE WITH USER'S GUIDE.)
Irrigation Pumps
Individual 'irrigation pump Permit for a lake froat lot ••
'Anach copy ($200)
Of vehicle registration
•� —�
Describe pump horsepower
�— and 8t�'c brand/modcl number
PLEASE REFER TO YOUR SHORE IMPROV _�_
SUBMIT TO •HE LAKE OFFICE OR
PLANNING PROVE NTS CR DEPARTMENT, P O OX 429, R IS GUIDE
MOUNTAIN. NC 28086
ALTERSHORELINEAPPLICATION. jsh

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