20140036 Ver 1_Application_20140109

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 stream impacts. Please provide seven (7) copies of this application and supporting
information as well as a non - refundable .application fee to the Division of Water Quality of $240.00
for impacts of to lake 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
1.
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Applicant Information
Owner /Applicant Information
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Name: D eh "I to L. 1 i o r /n}
Address: ,7, 3 2 �/ L? f�,f 's-
Mai-ling �4h�
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Ali -04" Gr�e, . -C !
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Telephone Number: 3 O - P o �7l37 2 LmJ Fax Number: 70 V - S -0 - sy
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E -mail Address: rV1 L4 n g o &C1,K r, v Ll 2 @�G y►� �: I s o m
Agent Information (A signed"and dated copy of the Agent Authorization letter must be attached
if the Agent has signatory authority for the ownier /applicant.)
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E -mail Address:
H. Project Information
Attach a vicinity neap 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 roust include a scale and north arrow. The footprints of all buildings, impervious surfaces, or other
facilities must be included.

1. Location
County: 0 f f a o wv erj Nearest Town: M -f a- i

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