20140284 Ver 1_401 Application_20140328

.. i
�Oflt� OF
•
•
E EIVEC
MAR 2 5 2014
RALEIGH REGULATORY
_ FIELD OFFICE
Abbreviated Application Form
For .regional General Permit 80 (Bulkheads and Riprap)
For Section 404 Regional General Permits, Section 401
General Water Quality Certifications, and Riparian Buffer and Watershed Buffer Rules
This application cannot be used for wetland or stream impacts.
i
This form is to be used for projects qualifying for the U.S. Army Corps of Engineers' (USAGE;) Regional
General Permits 80 (General Permit No. 197800080) as required by Section 404 of the Clean Water Act and for
the North Carolina Division of Water Quality's (DWQ) associated General 401 Water Quality Certification.
This form is also to be used for any project requiring approval under any Riparian Buffer Rules implemented by
the N.C. Division of Water Quality. This form should not be used if you are requesting an Individua1404
Permit or Individual 401 Water Quality Certification.
The USACE is the lead regulatory agency. To review the requirements for the use of General permits, and to
determine if general permit 80 applies to your project, please go to the USACE website at
www.saw.usace.army.miI /wetlands /index.html, or contact one of the field offices listed on page 4 of this
application. The website also lists the responsible project manager for each county in North Carolina and
provides additional information regarding the identification and regulation of wetlands and waters of the U.S.
The DWQ issues a corresponding Certification (General or Individual), and cannot tell the applicant which 401
Certification will apply until the 404 Permit type has been determined by the USAGE. Applicants are
encouraged to visit DWQ's- 40 1 /Wetlands Unit website at http: / /l12o.enr. state. nc. us /ncwetlands to read about
current requirements for the 401 Water Quality Certification Program and to determine whether or not Riparian
Buffer Rules are applicable. The applicant is also advised to read the full text of the General Certification (GC)
matching
ZZ: the specific 404 Pen-nit requested. Applicants lacking access to the internet should contact DWQ's
Central Office in Raleigh at (919) 733 -1786.
USAGE Permits - Submit one copy of this form, along with supporting narratives. maps, data forms. photos,
e c. o e app icable USACE Regulatory Field Office.
401 Water Quality Certification or Buffer Rules - All information is required unless otherwise stated as
optional. Incomplete applications will be returned. Submit seven collated copies of all USAGE Permit
materials to the Division of Water Quality, 401 /Wetlands Unit, 1650 Mail Service Center, Raleigh. NC. 27699-
1650. If written approval is required or specifically requested for a 401 Certification, then a non - refundable
application fee is required. In brief; if project impacts include less than one acre of cumulative wetland /water
impacts and less than 150 feet cumulative impacts to streams, then a fee of $200 is required. If either of these
thresholds is exceeded, then a fee of $475 is required. A- check made out to the North Carolina Division of
Water Quality, with the specific name of the project or applicant identified, should be stapled to the front of the .
application package. For more information, see the DWQ website at
http://h2o.chnx.state.iic.us/nc,,N,et]ands/fees.litml.
u , m 4"", 1C�svPS cry
Page i of 4 J3� i �-{e r; �� `�"�c�c�e Dr.
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Office Use Only:
US ACE Action ID No.
.2
W
Form Version August 2006
DWO No.
(If any particular item is not applicable to this project, please enter "Not Applicable" or "N /A".)
Applicant Information
1. Owner /Applicant Inforr
Name:
Mailing Address:_
Telephone Num
E -mail Address:
3U "�"(OID Fax Number:. ly
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner /applicant.)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E -mail Address:
II. Project Information
Fax Number:
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. Both the vicinity map and site plan must
include a scale and north arrow. The specific footprints of all buildings, impervious surfaces, or other
facilities must be included. If possible, the maps and plans should include the appropriate USGS
Topographic Quad Map and NRCS Soil Survey with the property boundaries outlined. Plan drawings,
or other maps may be included at the applicant's discretion, so long as the property is clearly defined.
For administrative and distribution purposes, the USACE requires information to be submitted on sheets
no larger than 11 by 17 -inch format; however, DWQ may accept paperwork of any size. DWQ prefers
full -size construction drawings rather than a sequential sheet version of the full -size plans. If full -size
plans are reduced to a small scale such that the final version is illegible, the applicant will be informed
that the project has been placed on hold until decipherable maps are provided.
Location
County:_ Nearest Toxin:
Subdivision name (include phase /lot number): kO&Ye,- IR � I Ot g
Site coordinates:
Decimal Degrees (6 digits minimum): °N °W
Directions to site (include road numbers /names, landmarks, etc.:
Page 2 of

3. Property size (acres): ' (' 19
4. Name of nearest named receiving body of water(stream/river /lake):
5. Describe the purpose of proposed w11 ork: ri- O-L
DC %GY�o e`fOSl6ri Aec I- i5 -t-O �hSUCe C,L ��c�MC�iAe�� e(�e�c�. �Oh
6. List t e type of equipment to be used to construct the project: QL Nva 'e— (`r
7. Type and amount of impact (including all back fill, excavation, riprap, retaining walls, other fill,
etc.) below the normal pool ake 1 vel in square feet or acres, and distance from shoreline:
V,D0 SC-\ -I�k
S. a. Type and amount of impact (including all clearing, back fill, excavation, riprap, retaining walls,
other fill, etc.) above the normal pool lake level and 50 feet land -ward in square feet or acres:
1 X10 sC-i C }
b. Please describe the vegetation ab e the normal pool lake level and 50 feet land -ward to be
impacted 1(nurnAr of tree � for instance): -4� r�C�xS
S
Applicant /Agent's Signature Date el
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 3 of 4

Full Pond
Shoreline
dowel area
11 ft s 160 ft
Lake (At Full Pond)
dock 3U tt x 1 ft
rip rap
5ftK150ft
„ lirluw full
;onl5ft x16Dft
.11111vc full
jiunil
EXAMPLE
See, MkicVej Plot plate
Please approximately sketch the following information on Vw. pl,in
(please provide dimensions for each item, such as 10 ft. x 1 r! it):
1) All proposed vegetation clearing jprovide dimensions)
2) Location of rip rap or'fill to be placed above the Full Pon ;, Pie-.,atlon
3) Location of rip rap or fill to be placed below the Full Pund osle-ratiun
4) The location of any proposed structures such as buildinc,, . retaining
walls, docks. etc.
5) The location of any excavation or dredging below the Fu,: Pond
elevation.
6) Location of construction access corridors.

Full Pond
Shoreline
Lake (Full Pond)
teS +o N' mll"
Please approximately sketch the follo-wfng information on this plan
(please provide dimensions for each item, such as 10 ft. x 100 ft):
1) All proposed vegetation clearing ( provide dimensions
_2) Location of'rip rap or'fill to hie placed abbe the Full Bond elevation
3) Location of rip rap or fill to be placed below the Full Pond elevation
4) The location of any proposed structures such as buildings, retaining
vralls_ docks, etc.
The location of any excavation or dredghig below the Full Pond
elevation.
6) Location of construction access corridors.

PROPERTY LEGAL DESCRIPTION:
LOT NO.�� ? PLAN NO. PARCEL ID:
STREET ADDRESS: ll g L S a q C,'C7�
Please print:
Property Owner:
Property Owner:
0
The undersigned, registered property owners of the above noted property, do hereby authorize
of
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
Telephone:
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature Authorized Signature
Date: __ Date:
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PROPERTY DESCRIPTI ®N Q /� -4 - -,A J
APPLICATION FOR -- /:improvements O Zoning O Electrical 00 e
(NOT A PERMIT) Permit Permit
RECN. # o'9 / 0 y/ V Proposed Ilse:
FORM 2302
Land use indicated (is) (is not) permitted in the zoning district. If permitted, the following minimum zoning
requirements must be met, unless the Health Department requires more land area or other qualifications are indicated in
-the remarks. Franklin County Zoning Ordinance does not supercede any-restrictive covenants placed on this property.
square Front yard ��ll Corner yard Aggregate
Lot area feet depth ft. depth ft. both sides
Side yard Rear yard 1�
Lot width feet depth ._.. ft. depth ft.
Remarks:
Permit No. Planning & Community Development
Pros by x •' Date
Required Information for IMPROVEMENTS PERMIT (Health Department)
Attach site plan showing property lines, location of proposed structures
(including driveways, patios, decks, etc.) and any existing structure.
Own on tax records j
M, C
Mailing Address
am.
No. of bathrooms
Tele hone No.
g
App ' ' nt
i t C 1164 e. / (�d'cf /� S�-a
Mailing Address
/!
�c
T lephon N
QW -9
No. of bedrooms per unit
O Business
Wastewater O Domestic O Industrial
• Other (Specify)
• Existing structure 0 Renovate O Addition Estimated Daily Waste Flow gal /day
Ta /M�a�p Nod!
Pgrcel 0.
Township L
Jurisdicti �
Zo n
Subdi ' ion r i
Lot No.
<90
Section No.
__
Lot Size
A
Road No.4'
Fl Plain
O Yes O No
Approx. Area
to be disturbed
Engineering Firm
Contact
Phone 0
Street address
Land use indicated (is) (is not) permitted in the zoning district. If permitted, the following minimum zoning
requirements must be met, unless the Health Department requires more land area or other qualifications are indicated in
-the remarks. Franklin County Zoning Ordinance does not supercede any-restrictive covenants placed on this property.
square Front yard ��ll Corner yard Aggregate
Lot area feet depth ft. depth ft. both sides
Side yard Rear yard 1�
Lot width feet depth ._.. ft. depth ft.
Remarks:
Permit No. Planning & Community Development
Pros by x •' Date
Required Information for IMPROVEMENTS PERMIT (Health Department)
Type of Facility (check one and complete) —
Single family dwelling
No. of bedrooms _ •i
No. of bathrooms
O Mobile home
No. of bedrooms
No. of bathrooms
O Multi- family dwelling
No. of units
No. of bedrooms per unit
O Business
Wastewater O Domestic O Industrial
• Other (Specify)
• Existing structure 0 Renovate O Addition Estimated Daily Waste Flow gal /day
Garbage Disposal Unit to be Installed O Yes O No Dishwasher O Yes O No Washer O Yes O No
Water Supply Source O Private O Public O Private off* site
Comment
Sanitarian Date Permit #
I certify that all of the statements made in this application and any attached documents are true, complete and
correct to the best of my knowledge and belief and are made in good faith. I understand that false information may
be grounds for rejection of this application. Authorized County Representatives are granted right of entry to snake
evaluati n or inspections d t�,role a e n ormation upon public request. {'
Signature of Owner or Authorized Agent Date
/7. — S . 1. C ZONING PERMIT EXPIRES IN SIX MONTHS.
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