20071542 Ver 1_Application_20070911

FRED BAIRD BLACKLEY, ASLA ~~1,~ ~,.~~.~~,~ . ~ ~ a~" )~~~
LANDSCAPE ARCHITECT ~8~ ~'~ '` ' '" 3
504 SOUTH DEKALB STREETij'L~ ~_",/
SHELBY, NORTH CAROLINA 28150 ~i ~ ~' ~ ~ ~(a(~
- [phone] 0 7- 1 5 4 2
~ENR - tNAI %:,R (lUA.LITY
Transmittal
To:
-I.~~YL~~~ ~=~+~-
Attn:
ut: ~~ ~~a~._
Project No:
Date:
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Copies Item ~~ Description
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For: APPROVAL INFORMATION RECORD REQUEST REVIEW COMMENT USE
Remarks:
Copy To: _,~~ ,Q, By: '
Via: US MAIL AIRBORNE__ PICK UP UPS FAX HAND DELIVER OTHER

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The following is an abbreviated application form for those applying fora 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 seven (7) copies of this application and supporting information as well as a
non-refundable application fee to the Division of Water Quality of $200.00 for
impacts of to lake bottom of less than 1 acre and $475.00 for impacts to lake bottom
of greater or equal to 1 acre.
Applications should be sent to:
Division of Water Quality Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
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I. Applicant Information
1. Owner/Applicant~~~I~ggnformation
NamP.' fi'l.C~~rr~C., '~ f~(.S
Mailing Address: ..30•f ~l 5t i'-ews
.r~; k! SG- 0.2..9
Telephone Number: `7~ ~ 9a (~? 7/ Fax Number:
E-mail Address: Gtr./l~ 7a @ i~ciEl~o• C6~
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:
Telephone Number: Fax 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 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
County: ~~ Nearest Town: ~~i.-L~
Subdivision name or site address (include phase/lot number): ~rM~ Z
Directions to site please include road numbers, landmarks, e c (This is not
necessary if an adequate vicinity map is included): r C~l~
2. Describe the
3. Property size (acres):
use or
site rat~the time of this
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4. Nearest body of water (stream/river/sound/ocean/lake):
5. Describe the purpose of
6. List the type of equipme
work:
~~
be used to construct the prof
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7. Amount of impact (including all excavation, backfill, rip~ra ,~,, retaining walls, ~
etc.) below the normal pool lake level in square feet or acres: -1- p~ ~' 1 X ~ 1) Wcu~ 2
a. Amount of impact (including all clearing, back fill, excavation, rip rap,
retaining walls, etc.) above the normal pool lake level and 50 feet land-ward in
square feet or acres:~~ L ~ ~ ~•-(~ Wl~u'? ~.U,B C~.~
b. Please describe vegetation above the normal pool lake level and 50 fe t lan~-
ward to be impacted (number of trees for instance): ~rp~ ~ 1;~ }-~~tt>~a ,
IC ~~v :? ~ ,F~ In .

Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

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