19990264 Ver 2_401 Application_20130712

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The Moving is an abbreviated application form for those applying for a 401 Water Quality
Cer ca#lon to impact FEBC (Federal Energ9 Regulatory Ca— fission) regwwa lake shore or
bottom under the U.S. Army Corps of Engineers Petmft GPO. This Appiieation cannot be used
for wetland or stream impacts. Please provide seven (7) copies of this application and supporting
information as well as a u n-refuadsble application fee to the Division of Water Quality of $240.00
for impacts of to lake boom of less than 1 acre and $570A0 for impacts to lake bottom of greater
or equal to 1 acres
a-plications should be seat to.-
Division of Water Quab► 401 Ov fE I Review Permitting
1650 Mail Service Center
Raleigh, NC 27699 -1650
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Applicant lnformnhon
1. QwnedApplicant won
Name:
Mailing Address:
2.
Telephone Number.
E-mail Address:
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- Jo9 y�� Fax Number:
Agent Information (A signed and dated copy of the Agent Autiioiization letter must be attached
if the Agent has signatory authority for the ownedapplicant.)
Name: -
Company Affiliation:
Mailing Address:
Telephone Number.
II. Project Iffiormation
Fax Number.
Attach a vicinity map dearly showing the location of the property with respect to local Iandnmts such
as towns, rivers, and roads. Also provide a defiled site plan showing property boundaries and
deveIopr o nt plans in relation to surrounding properties. You may use the diagram below to make a
hand sbtch of your project. Also, see the example Mow for guldanoe. Both the vicinity map and site
plan must include a scale and north arrow. The footprints of all buildings, impervious surfaces, or other
facilities most be included.

1. Location
County: / Nearest Town:
Subdivision name or site address (include phase/lot number): "4411e4
Directions to site please include road numbers, landmarks, etc. (This is not necessary if an adequate
vicinity map is included): Sew G.o
Z. Describe the existing land use or condition of the site at the time of this application:
3. Property size (acres):
4. Nearest body of grater
5.
Describe the purpose c
•S
b. List the type of equipment to be used to construct the project c %lve S/,
7. Amount of impact ( including all 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 rap, retaining walls, etc.)
above the normal pool lake Jevel and 50 feet land -wa in square fig or acres:
8.b. Please describe vegetation above the normal ool lake level and 50 feet landward to be impacted
(number of trees for instance):
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Applicant/Agenfs Signature bate
(Agent's signature is valid only if an authorization letter from the applicant -is provided.)
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