20140778 Ver 1_Application_20140723

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'The follawing is an abioevated Wficadion farm for thole ?Q"4 ® 7 7 8
Certification to impact FMC (Federal for a 401 Water
bottom oader the U.S. p9 � . ` . ) lake sboi+e or
Army Cusps of Plennit GP31L This Application cannot be Deed
for wetland or stream Wmacts PbMe provide seven M ©opd of and sag
infor>oa�*4 as well as a nee hie fee to the DWdDK of Water Qoal ty of $:Op
for hwacts of to lake bottom of hm than 1 am and V7WO hr,hquds to Inge bonmof St's'
or equal to Z acre.
Applications should be sent to
Division of Water Qualify 401 0v +&jWWE4 giffkW pauwgng
1550 Mail Service Ceafrr
Raleigh, NC 27614650
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2.
OwnedApplicant Info ion
Name:
Mailing
20,
I\fR WA
v�WX'CIs.& -zt_7 ALITY
Telephone, Number: -a30 512 Fax Nt 3�0 l -1 3 Ulk-
E -mail Address: C aO d legac y- by i I d q Q c,�
Agent Information (A signed and dated copy of the Agent Anthoon letter must be attached
if the Agent has sigaatoty amity for ft ownentqVfic=t )
Name:
COMIMY AM
Address:
Telephone Number:
E-mail Address:
U. Project Information
£apt Number:
Anwh a vicinity map clearly showW the location of the prloWM with taspect to local landmarks such
towns, river§, and mods. Also provide a detailed she pwa Aowmg ply bomdmies and
development pleas m relation to PrOPCItM You may use the diagram below to make a
hand sketch of your projec. Also, at the example below for guidance. BO& tt vicinity map and site
plan must include a sole and north arrow. The fad of all cgs, mqxwvxxn surfaces, or Odwr
fxilities must be included.

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1. Location
County: S0!!:j Nearest Town:
Subdivision name or site address (include phase/lot number): (�f '' - I q
Directions to site please include road numbers; landmarks, etc. (This is not necessary if an dequate
vicinity map is included): F72M r L
e 4um
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2. Descnbe the existing land use or condition of the site at the time of this application:
3. Property size (acres):
4. Nearest body of water (stream/river /sound/ocTk!i"Ll ��-
C
5. De be the urpose of the proposed work: 4Z
-MvM 2(0 r
6. List the type of equipment to be used to cow the project: .S452-r
7. Amount of impact (including all excavation, backfll, rip rap, retaining walls, etc.) below the
normal pool lake level in square feet or acmes: '
8.a. Amount of impact (including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
above t e porfnal pool lake=l�vel and 50 feet land -ward in square feet or acres:
8.b. Plcasc describe vegetation above the normal pool lake level and 50 TA landward to be impacted
(number of trees for instance): ` S
(Agents signature is valid only if an authorization letter from the applicant is provided.)

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