20130395 Ver 1_401 Application_20130415

Y- . . . -
20130395
The following is an sbb appliaatiOn form for those applying for a 401 Water Quality
Certification to in qmd FMC (Federal Ibim q RegolatM Comm f 1110 n) regulated lake shore or
bottom under the U.S. Army Coma of ft&eers Permit M& TLis Appiicadon cannot be used
for wetland or stream b4uwts. Please provlde seven (7) copies of this application and supporting
informat�larr as well as a non- reflnn"e applicatlon free to the DhMon of Water Qoalfty of $240.40
for impacts of to lake bottom of l+em than 1 acre and $ 570.00 for impacts to lake bottom of greater
or equal to 1 acre.
Appiicatiauns should be sent to:
Division of Water Qty 401 oversigl�►
1650 Mail Service Center
Raleigh, NC 27699-1650 APR 1 5 2M3
L Applicant Lnformatiion D AUT
1. 4wnedApplicant Iafioamation
• Y
NQii1N
Mailing Address:
Telephone Number: Fax Number.
E-mail Address:
2. Agent hdbnnation (A signed'aad dated a py of the Agent Authorization letter mast be attached
if the Agent has signdmy authority for the owneedapplicent.)
Name: '
Company Affiliation:
Mailing Address:
Telephone Number-.
E -mail Address:
IL Project €n€, L----
Fax Number:
Attach a vllck ty prep clearly showing the location of the property with respect to local landmarks such
as t+ owns, rivers, and roads. Also provide a detailed site plan strewing property boundaries and
development plans in relation to surrounding propmties. You may use the diagram below to make a
hand sketch of your project. Also, we the example below for guuidance. Both the vicinity map and site
plan must include a scale and north arrow. The footprints of all buildings, impervious smf ms, or other
facilities mast be included.

1. Location /
county. Nearest Town:
Subdivision name or site address (include phase/lot number):
Directions to site please include road numbers, landmarks, etc. (ibis is not nay if an adequate
vicinity map is included):
2. Describe the existing land use or condition of the site at the time of this application: "'a ,
3. Property size (acres):
��tcres
4. Nearest body of water (streamtriver/ sound /ocean/lakke): -Z�Mi-
5. Describe the purpose of the proposed work: 00 :6.4
6. List the type of equipment to be used to construct the project
7. Amount of impact ( including all excavation, backfill, rip rap, retaining wails, etc.) below the
normal pool lake level in square feet or acres:
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 Ind-ward in square feet or acres:
8.b. Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance): -c�i� s
Applicant/Agent's Signature bate
(Agent's sib is valid only if an authorization letter from the applicant is provided.)

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