20140968 Ver 1_Shoreline Stabilization_20140910

20140968
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 seven (7) copies of this application and supporting
information as well as a non - refundable application fee to the Division of Water Quality of $240.004
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 RECEIVE
Raleigh, NC 27699 -1650
I. Applicant Information
Owner /Applicant Information
Name:
SEP 10 2014
DENR -LAND QUALITY
STORMWATER PERMITTING
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Telephone Number: �(D- !I—B!3 - 1-70,a Fax Number: 3,36 Zk24
E -mail 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: JIMMY LEWIS & SONS GRADING & SEPTIC, INC.
Company Affiliation:
Mailing Address:
Telephone Number:
E -mail Address:
II. Project Information
1024 HENRY STREET ROXBORO, NC 27573
336- 599 -9890 Fax Number:
336- 599 -1806
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.

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1. Location
County: ��I .10n Nearest Town: V OXbQY-Q
Subdivision name or site address (include phase/lot number): a VV h 1 WM(_ J I I Ln .
Directions to site please include road numbers, landmarks, etc. (This 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 applicationh
"A" n �
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3. Property size (acres): I r p,
4. Nearest body of water ( stream /river /sound/ocean/lake):�M1
5. Describe the purpose of the proposed work:
ICn
6. List the type of equipment to be used to construct the project: "1 n i PX00t ynkc
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls, etc.) below the
normal pool lake level in square feet or acres:
5v,O ca 4&+helOv\i DPI into, icAye_I
8.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:
8.b. Please describe vegetation above the norm[ al pool lake level and 50 feet landward to be impacted
(number of trees for instance): ll Qy_,�&
9NIPI
Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

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Please approximately sketch the f+ wing iffarination an ttds plan
(please provide dkoenslons for each stern, such as ftl ft. x IN ft):
9) All proposer! Ye9dation dearing (provide dlmenW ns)
A Locaction of rip rap or fill to be placed above the Fu l Pond elevation
3) Location of rip rap or fill to be placed below the RA Pond elevation
A Ttw location of any proposed stuctures such as buildings, retaining
wafts docks, etc.
6) The location of any excavation, or dridging below the, Fui[ Pond
elevation.
B) Looefl on of construction cr ocess corridors.
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RECEIVED
10 2014
DENR -LAND QUALITY
STORMWATER PERMITTING
Please, approximatety sketch the following i orina n on tws plan
(please provide drmenslons for each Item, such as 10 f. x 100 Ft);
11) AV proposed vegetation clearing (provide dimensims)
A Location of rip rap or fill to be, placed above the punt Pond eleva n
3) Location of rip rap or fill to be placed below the Full Road elevation
4) The location of any proposed etu- d-um such as buildings, retaining
aa; aHsP docks, etc.
6) The location of any excavation or dredging belowthe Full Pond
elevation.
6) Location of construcUon aocess corridors.