20140757 Ver 1_Application_20140721

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AUG -01 -2012 09'25 l y
201 40757
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 ' cation fee to the Division of Water Quality of $240.00
information as well as a non-refundable pp acts to lake bottom of greater
for impacts of to lake bottom of less than 1 acre and $570.00 for imp
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 NC 27699 -1650
Y. Applicant Information
JUL 21,14
1. Owner /Applicant Information _ 0 NR
LE}L E t2- Branch
Name:
Mailing Address*
Telephone Number: H' '` I " Fax Number
Ismail Address:
2 Agent 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:
Fax Number:
Telephone Number:
E -mail Address:
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 boundanes 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 of all build gs Both
mpervious surfaces, dr other
plan must include a scale and north arrow. The footprints
facilwes must be included.

- w4 (,14 4460 P 002
location
County % V a IZ n n% Nearest Town- Won %
Subdivision name or site address (include phase/lot number): Chl7 ,3 -cf47
Directions to site please include road numbers, landmarks, etc. Mus is not necessary if an adequate
vicinity map is included):
2. Describe the existing land use or condition of the site at the time of this application
3 Property size (acres)- i, b-3 % 4crc,-
4 Nearest body of water (stream/river /sound/ocean/lake) C's /, kO
5 Desenbe the purpose of the proposed work, c- ,d�_W c?
6 List the type of equipment to be used to construct the project.
7 Amount of impact (including all excavation, backfJl, rip rap, retaining walls, etc.) below the
normal pool lake level in square feet or acres: O,i Z G
8 a Amount of impact (including all clearing, back fill, excavation, np rap, retaining walls, etc )
above the normal pool lake level and 50 feet land -ward in square fleet or acres
Vi Z— — s4®t?
8.b. Please describe vegetation above the normal pool lake level and 50 feet Iandward to be impacted
(number of trees for instance):
/4ll-_,e A-7or 17a %-ems Gdr fLa /v¢
AppiicanVAgent's Signature Date
T— 14
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

APPLICATION FOR PERMIT TO CONSTRUCT OR ALTER
THE SHORELINE / CONTROL STRIP OF JOHN H. MOSS RESERVOIR AREA
DATE OF APPLICATION i Co J o i e 261
APPLICANT(S) CA o n( Ic2 C--r1 c4 P r
OWNER(S) Gj a m 0
,/OWNER(S) MAILING ADDRESS P6 '(3 Ox 14 0 G
,/'OWNER(S) SIGNATURE(S) ---"
ADDRESS OF LAKE PROPERTY 12 j 2 0 e to C rC4 Lone
SUBDIVISION NAME n i n e C�-f `° a(
TAX MAP (,, - 4 F - -L- 23 BLOCK '2 LOT
CURRENT LEASE #
PIT q1A
TELEPHONE # FOR CONTACT-(14 -'(HOME) i, q m e- (WORK)
WIDTH OF LOT AT SHORELINE % 5 � 571 t
NAME AND PHONE # OF ENGINEER OR ARCHITECT:
Clucale. Rec�oermonI PEh _-70 Gq /7 5
NAME AND PHONE # OF CONTRACTOR (' omo,:,W 11 wr)srn(g8a� 2 %f `?. 4
PROPOSED CONSTRUCTION AND /OR ALTERATION OF SHORELINE
SEE ATTACHED PLANS
(CIO APPLICATION CAN BE REVIEWED WITHOUT PLANS MADE IN ACCORDANCE WITH USER'S GUIDE)
Imgation Pumps
Indroidual irrigation pump permit for a lake front lot ** ($200)
*Attach copy of vehicle registration
* *Describe pump horsepower and gi,,e brand/model number
PLEASE REFER TO YOUR SHORE IMPROVEMENTS CHECK LIST AND USER'S GUIDE
SUBMIT TO THE LAKE 01 -FICE OR PLANNIING DEPARTMENT, P O BOX 429. KINGS MOUNTAIN, NC 28086
ALTERS HORELINEAPPLICATIONjsh
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