20071564 Ver 1_Application_20070914

FRED BAIRD BLACKLEY, ASLA
LANDSCAPE ARCHITECT ,
- 504 SOUTH DEKALB STREET
SHELBY, NORTH CAROLINA 28150 -y /J
- [phone] O r ~ ~ ~ ~ '*
Transmittal
To: ~ (51n v`~,`, Attn:
s~
V ~ ~ V-~t ~ Pro3ect:
~(, ~Cs 2'f (~~~ ~ C6~ Date: ~ ~ ~ 0~_
Copies Item ~ Description
For: APPROVAL INFORMATION RECORD REQUEST REVIEW XJ COMMENT USE
Remarks:
SEP 1 4 2007
DENR -WATER
~,~ETLAND3 AND STORluAr1ATER BRANCH
Copy To: _,
sy:
Via: US MAIL AIRBORNE_~ PICK UP UPS FAX HAND DELIVER OTHER

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.
07-1.564
Applications should be sent to:
Division of Water Quality Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
I.
Applicant Information
Owner/Applicant Inf
Name: ~~
Mailing Address:
Telephone Number:
E-mail Address: G
o ~,C~C~a~~ D
SEP 1 4 2007
~~j~~ gTpRNpNA76R
Fax Number:
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 Affilia~
Mailing Address:
Telephone Number:
E-mail Address:
II. Project Information
Fax Number:
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 \ (~ '• .~ oo
County: ~ ~ ~ 1 ~ !t~/~t Nearest Town:
Subdivision name or site address (include phase/lot number): ~ ~ D D 1
Directions to site please include road numbers, landmarks, etc. (This is not
necessar~if an adequate vicinity mad is included):
2. Describe the existing l~an~
3. Property size (acres
use or co dition o~ the
r/
~ 4' Gl,l~ ~ ~ ~-
4. Nearest body of water (stream/river/sound/ocean/lake) ~J ~~~U~ ~/~^'~''~-
5.
6. List the type of equipment to be used to construct the project:~~i~ S ~~~ 1~J~
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls,
etc.) bed the normal pool lake level in square feet or acres: ~ ~~~ ~ h ~~
~ ~~~ ~ F
8. a. Amount of impact (including all clearing, back fill, excavation, rip rap,
retaining walls, etc.) afire the normal pool lake level and 50 feet land-ward in
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square feet or acres: '~ `Z ` ~ Zf
G ~~ c.s
b. Please describ vegetation above the normal pool lake level and 50 eet land
ward to be impacted (number of trees for ins~ta~ce): WYE ~ ~ 1
-.~
at the time of this
~~
~'~ .
Applicant/Agent's Signa e ~ Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

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