20140018 Ver 1_Application_20131230

201400 1 8
The following is an abbreviated application form for those applying for a 401 Water Quality
Certification to impact FERC (Federal Energy Regulatory Commission) regulated lake shore or
bottom under the U.S. Army Corps of Engineers Permit GP30. This Application cannot be used
for wetland or steam impacts. Please provide five (5) copies of this application and
supporting information as well as a non - refundable application The to the Division of Water
Quality of $240.00 for impacts to Iake bottom of less than 1 acre and $570.00 for impacts to
lake bottom of greater or equal to 1 acre.
Applications should be sent to:
Division of Water Quality 401 Oversight/Express Review Permitting �►�
1650 Mail Service Center
Raleigh, NC 27699 -1650 •� t? ��._'
I. Applicant Information
1.Owner /Applicant Information
Name: !S,�Yw 19 ybj,
Mailing Address: i 4' Ca
Telephone Number: o q - - gyq Fax Number: �-
E-mail Address: -��
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be attached
if the Agent has signatory uthority for the owner /appl' nt.)
Name: l_N�aat C U�& � (f / 5 oy n <.
Company Affiliation: O KAxt r
Mailing Address: 3
Telephone Number: Tai- a3g1 -L5'93 Fax Number:
E -mail Address: C C X Y-3 3 & Ao t, , Eda^
II. Project Information
Attach a vicinity map 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 boundaries and
development plans in relation to surrounding 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.
1. Location
County: T,d�d' Jc j Nearest Town:
Subdivision name or site address (include phase/lot number): o .b0 3
Directions to site please incl yde� road numbe landmR s, etc. (This " of necessary if an adeq ate
vicinity map is included): F'tt�� 1 �0 - GI•,9oyt ,Qd - ra/,
:I_-
2. Describe the existing land use or condition of the site at the time of this application: C900c, JSU6 le-
3. Property size (acres): s YJ, A-(AS
4. Nearest body of water (stream/river /sound /ocean/lake): L.4t 00NAM
35,55RR SD.al'id.l

5. Describe the purpose of the
,proposed work:
6. List the type of equipment to be used to construct the project: Cal 21-7 f� : �S��ci/if, "14,"
7. Amount of impact (including all excavation, bac�iretaining walls, etc. below the IO
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 land -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): ifte- , All PITTA S S
c/'
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

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(Page 1 of 1)
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0.68 RE
169
I .PIN ��, 60�� ��O ^• �� J�
�° -PIN
J ? 9L d�
LOT 97 /
LOT 104
0.81 am y I -PI 165 0.60 RCRE f�� ��� d� 156 I -PIN
�/s0 OOOLEY
LOT 98
`r9 / 0 .'n RCM
NZI
M
_ 760 CONTOUR LOT 103 I -PIN
a� (.
0.62 AC �V 158
RE I .PIN
905TWALT .4 ` q, Q
SECTI N 8 ,4., ^* LOT 99
'y �► `� G ,y 0. TO ACAF
' IREDELL � .�� r` �� G a Ise
COUNTY W �'�`` I -PIN
r
c i o ooh _
RAPHIC LOCATI a = '-
,ALE: t = 2 MILES o LOT 100 158 I•PIN
0.78• AQU
CRESCENT LAND 4 TIMBER
�P� ��job, ` �roa 760 CONTOUR t H. C. BAILY )
U. M. I. - 262
664.000 LOT 101
+ �.�� �,�.�� 0.93 AGRE _� 160 I .PIN
.. L R K E N O R M A N
'ANY TO CRESCENT LAND t o
-ED BOOK 401 PROE 91.
d6s N
Book: 15 Page: 43 Seq: 1

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