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HomeMy WebLinkAbout20051673 Ver 1_Application_20050830,• APPLICATION fOR DEPARTMENT OF THE ARMY PERMIT OMB APPROVAL NO. 0710-0003 /33 CFR 325/ Expires December 31, 2004 The Public burden for this collection of information is sestimated to average 10 hours per response, although the majority of applications should require 5 hours or less. This includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Service Directorate of Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302; and to the Office of Management and Budget, Paperwork Reduction Project (0710-0003(, Washington, DC 20503. Respondents should be aware that notwithstanding any other provision of law, rto person shall be subject to any penalty for failing to comply with a collection of information if it does not dicplay a currently valid OMB control number. Please DO NOT RETURN your form to either of those addresses. Completed applications must be submitted to the District Engineer having jurisdiction over the location of the proposed activity. PRIVACY ACT STATEMENT Authorities: Rivers and Harbors Act, Section 10, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; Marine Protection ,Research and Sanctuaries Act, 33 USC 1413, Section 103. Principal Purpose: Information provided on this form will be used in evaluating the application for a permit. Routine Uses: This information may be shared with the Department of Justice and other federal, state, and local government agencies. Submission of requested information is voluntary, however, if Information is not provided the permit application cannot be evaluated nor can a permit be issued. One set of original drawings or good reproducible copies which show the location and character of the proposed activity must be attached to this application (see sample drawings and instructions) and be submitted to the District Engineer having jurisdiction over the location of the proposed activity. An atwlication that is not completed in full will be returned. - 1. APPLICATION N0, ~ 2. FIELD OFFICE CODE ~ 3. DATE RECEIVED 14. DATE APPLICATION COMPI~mEp ~ °m D z ~. A ~ ~ ITEMS BELOW TO BE F/LLED BY APPLICAN ~ ~ ~ 5. APPLICANT'S NAME 8. AUTHORIZED AGENT'S NAME AND TITLE lanagentlequiri'>~ C""-~` a a 1,, L r~ o "nY J 6. A PLICANT'S ADDRESS 9. AGENT'S ADDRESS z ~N~~:ll~, ~-~ Z~~~~4 r~ ' ~'~ct11~1~i'1 ~cn~ /tlG ~~~8~ ~ , . 7.. APPLICANT'S PHONE NOS. W/AREA CODE 10. AGENT'S PHONE NOS. W/AREA CODE a. Residence C~'f l t~ ~ ~ Z lv " ~' I y 3 a. Residence b. Business ~ ~'~ (vl ~td, S ~~~ ~- ~ b. Business (~~~.. ~~~ / V ~J I hereby authorize, furnish, upon request, 20051673 to act in my behalf as my agent in the processing of this application and to information in support of tfiis permit application. ._i3-~ APPLICANT'S SIGNATURE DATE NAME, LOCATION AND DESCRIPTION OF PROJECT OR ACTIVITY 12. PROJECT NAME OR TITLE lsee inSTructions. 1.~,16~-.~I-~r ~~~t-~ ~1.~~~.-Q~'~ ~~~1~ Svl~~rr~~~s~~~~~ 13. NAME OF WATERBODY, IF KNOWN IifepplicetNel 15. LOCATION OF PROJECT ~~~ti ~k.Y^ A It,~r. ~f~ COUNTY STATE 14. PROJECT STREET ADDRESS rrapprr~ae! ~d~~~~ C~-~ i4~ ~ ~ i `~" ?6. OTHER LOCATION DESCRlPTiONS, 1F KNOWN, ;see instructions! 17. DIRECTIONS TO T~E SITE - ~ 1 i ~ ~+ ~~ ~ '~~y,~~,~~i,K ~'~~-(3~ 1rVt ~' ~c~ 1 N"~'~v~s ~'11~71.. w t' ~1 ~ ~~' cc~w' ~r ,~ 4r ~- ~ti~s fi c R 4 u 7 EDITION OF FES 94 IS OBSOLETE. (Proponent: CECW-ORi 18. Nature of Activity (Description of project, include al! features/ ~ ~R~ dP ~ti~ cF ~` ~~~~ j ;`wz~~~ t'~~ ~~I;,~j ~,t;f~.c~ ~~-- ~~/ Q,V ~ 19. Project Purpose (Describe the ~ea~, or purpese o! the propecr, see inatructior~l USE BLOCKS 20-22 IF DREDGED ANDIOR FILL MATERIAL tS TO BE DISCHARGED 20. Reason(s)for Discharge 21. Type(s) ofiMaterial Being Discharged and the Amount of Each Ttipe i^ Cubic Yards •-2d1^~k ~= ~(~ ~ ip--t~- . ~5= ~ 22. Surface Area in Acres of Wetlands or Other Waters Filled Iseainsrructionsl ©t C~ ~(- cam. = ~3 ~„~ ~~~~~-~~ 23. Is Any Portion f the W k Already Com late? Yes J~ No IF YES,.D~JSCRIBE THE COMPLETED WORK y0.>~-Ci~1 ~il~ ~vi^ `~V'~ C~ ~QFt•-~t~ ~' ~GLcI°j4' -~'~b~lTjti+~r 24. Addresses of Adjoining Property Owners, Lessees, Etc., Whose Property Adjoins the Waterbody (If more than can be entered here, please attach a supplem ntal list). ~c~.t. ~ I`S'~ 25. List of Other Certifications or Approvals/Denials Received from other Federal, State or Local Agencies for Work Described in This Application. AGENCY TYPE APPROVAL" IDENTIFICATION tiunaRFCt nerG eaai icn nATG 'Would include but is not restricted to zornng, building and flood plain permits 26. Application is hereby made for a permit or permits to authorize the work described in this application. I certify that the information in this application is complete and accurate. I further certify that I possess the authority unde take the work described herein or am acting as the duly authorized agent of the applicant. SIGNATURE OF APPLICANT DATE IGNATURE OF AGENT DAT The application must be signed by the person who desires to undertake the proposed activity (applicant) or it may be signed by a duly authorized agent if the statement in block 11 has been filled out and signed. -_--__.. __. __._._.__._.~~.. ..r..~r~., ~,~v v,9lC llrrflV YLU UH~t UtIV~tU 18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals, or covers up any trick, scheme, or disguises a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious or fraudulent statements or entry, shall be fined not more than S 10,000 or imp-isoned not more than five years or both. # 206: 1) Abul K. Azad and wife 4435 Ferncreek Drive Fayetteville, NC 28314 2) Daniel S. Gordon 4609 Weaverhall Drive Fayetteville, NC 28314 3) J.K. Lormand 505 Lost Tree Court Fayetteville, NC 28314 4) Terry and Katherine McKnight 4427 Ferncreek Drive Fayetteville, NC 28314 1`1 ~' ~ L~R~ AND S pg 3397 . 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