20030430 Ver 2_401 Application_20130712

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The following is an abbrevlated application form for those applying for a 401 Water Quality
Certi6catiwi tm impact FEBC (Federal Lner" RegulaWy Commission) regulated lake shore or
bottom under the U.S. Army Corps of Facgineers Pwmk GP30. This AppHeation cannot be used
for wetland or stream impacts. Please provide seven (7) copes of this application and supporting
information as wa as a non refandeMeappaicallon fire to fire Division of Waterr Quality of VA-00
for impacts of to lake bottom of less tban 1 acre and $670.00 for Impacts to lake bottom of greater
A or equal to 1 acre.
Applications should be sent tw
Division ,of Water QuWhy 401 Oversi� Review Pa=nting
1650 Mail Service Center
Raleigh, NC 27699-1650
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2.
Applicant Loformation
Owned/Applicant Information
Mailing Address: 2G�}6n ►7 R .
211 e-vHf a-7 Fe 4
Telephone Number. 9/O- // 3 9 ` 5'334 Fax Number:
&mail Address:
e
Agent Information (A signed'hnd dated copy of the Agent mthorization letter must be attached
if the Agent has signatory authority_ for the ownedapplicant.)
Name:
Company Affiliation:
Mailing Addre :
Telephone Number_ Fax Number:
E-mail Address:
IL Project Information
Attach a vicinity ump dearly showing the location of the property with respect tea .local landmarks such
as towns, rivers, and roads. Also provide a detailed site plan showing property boundaries and
development plans in relation to sammding lea. You may use the diagram below to make a
hand sketch of your pr jea Also, see the example below for guidance. Both site vicinity map and site
plan must include a scale and north arrow. The footprints of all buildings, in4mvious surfaces, or other
facilities must be included.

1. Location
County: -!lid/ • Nearest Town W4,70-,
Subdivision name or site address (include phasellot number):
Directions to site please include road numbers, landmarks, etc. (This is not necessary if an adequate
vicinity map is included): f LW
2. Describe the existing land use or condition of the site at the time of this application: p', e,.
3. Property size (acres): 0' 3 N C��y
4. Nearest body of i6ter ( stream /rivedsoundtocean/iake): /LY
5. Describe the purpose of the proposed warlc
6. List the type of equipment to be used to construct the project: A14C
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls, etc.) below the
normal pool lake level in square feet or abres• V� �K 9 © 0 u cv S e< F�'
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 land-ward in square feet or acres:
.�- A- 9 e � 2�1 6 5,&
8.b. Please describe vegetation above the normal pool Iake level and 50 feet landward to be impacted
(number of trees for instance): �C Qvi' �isf ft
/11� -aal- /3
Applicant/Agenes Signai&e bate
(Agent's signature is valid only if an authorization letter from the applicant is provided)

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