20140494 Ver 1_Application_20140515

20140494
(� PAID
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 trader 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. Applicant Information
Owner/
Name:
Mailin€
4
12(KMW C
MAY 1 5 2014
r+FR - w" a R 166 ��rY
k#xXW 4 stria w&{ yr Branch
Telephone Number: Z2y 6rf Fax Number:
E -mail Address:
2. Agent Information (A signed-and dated copy of the Agent Authorization Ietter must be attached
if the Agent has signatory authority for the owner /applicant.)
Name:
Company Affiliation:
Mailing Address:
Telephone Number. Fax Number. _
E -mail Address:
IZ 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
,�/ cg►� Nearest Town:
County: / /�'1 --
Subdivision name or site address (include phase/lot number): #
Directions to, site please include road numbers, landmarks, etc. (This is not necessary if °an adequate
vicinity .map i's included): y
2. Describe the existing land use �or condition of the site at the time,of'this application:
3. Property size,(acres):
IJ
RI
91
7.
Nearest body of water
Describe the purpose c
List the type of equipment to'be used to construct the projeciX
Amount of `impact-(including all excavation, backfill, ,rip rap, retaining walls, etc.) below the
normal pool lake level in,square feevor acres:
8.-& Amount of impact (including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
above the normal pool lake level and 50 feet l n j square fee acres: X
-- fz -�,�
8.b. Please describe vegetation above the normal pool lake level and 5 feet landward to be impacted
(number of trees for instance):
Applicant/AgenVs Signature bate
(Agent's signature is,valid only if an authorization letter from the applicant is,provided.)

HbOld
- pv
--River H
$` � _ ' ^ -��... - - _ _ —.- - •�.r.___ - _ _-° � •iiF tee% _`� ���_R :. -.. ,,p i
__River
27
_ - - - ' €_= --_ - -_ _ -_ -- - - � - ate= _ = --• --, . - "_ , -. - -\e�- - :�,�_�`; - • _�r ,f';�` -- -> � -_ - , --- - _ - _ 'a

{ f.
� \\
!
. ,. ( � 2
.}_. � }� �
� � � � �� \
\ \ &�\��
. � 1' � «
` » «�
^`� ~ ,d �� �
�{ »you f�
a)}�� %�)
\ � \��