20141060 Ver 1_401 Application_20141014

b�M OCT 0 �0 2014
20 1 4 1 06 0
Office Use Only
Corps achow -A . ID no
DWQ project no
Form Version 1 4 January 2009
Pre - Construction Notification (PCN) Form
A
Applicant Information
1
Processing
Al
Type(s) of approval sought from the Corps
S Section 404 Permit ❑ Section 10 Permit
1 b
Specify Nationwide Permit (NWP) number or General Permit (GP) number
1 c
Has the NWP or GP number been verified by the Corps?
❑ Yes ❑ No
b�M OCT 0 �0 2014
20 1 4 1 06 0
Office Use Only
Corps achow -A . ID no
DWQ project no
Form Version 1 4 January 2009
Page 1 of 10
PCN Form – Version 1 4 January 2009
Pre - Construction Notification (PCN) Form
A
Applicant Information
1
Processing
1 a
Type(s) of approval sought from the Corps
S Section 404 Permit ❑ Section 10 Permit
1 b
Specify Nationwide Permit (NWP) number or General Permit (GP) number
1 c
Has the NWP or GP number been verified by the Corps?
❑ Yes ❑ No
1d
Type(s) of approval sought from the DWQ (check all that apply)
❑ 401 Water Quality Certification – Regular ❑ Non -404 Jurisdictional General Permit
❑ 401 Water Quality Certification – Express ❑ Riparian Buffer Authorization
le
Is this notification solely for the record
For the record only for DWQ
For the record only for Corps Permit
because written approval is not required?
401 Certification
❑ Yes ❑ No
❑ Yes ❑ No
If
Is payment into a mitigation bank or in -lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank
❑ Yes No
or in -lieu fee program
1g
Is the project located in any of NC's twenty coastal counties If yes, answer 1h
below
❑ Yes No
1h
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
❑ Yes ❑ No
2.
Project Information
2a
Name of project
sC Q a
2b
County
2c
Nearest municipality / town
2d
Subdivision name
y1 e a `
2e
NCDOT only, T I P or state project no
3.
Owner Information
3a
Name(s) Recorded Deed
�� }�_T / � a
�" —" /7
3b
Deed k
Deed Book and Page No
3 �"'�%
7
3c
Responsible Party (for LLC if
applicable)
3d
Street address
j
3e
3f
City, state, zip
Telephone
f„ jV. $2 ?�
/ Y
no
Q _ _ q
3g
Fax no
3h
Email address
Page 1 of 10
PCN Form – Version 1 4 January 2009

4. Applicant Information (if different from owner)
4a Applicant is
❑ Agent ❑ Other, specify
4b Name
4c Business name
(if applicable)
4d Street address
4e City, state, zip
4f Telephone no
4g Fax no
4h Email address
5. Agent/Consultant Information (if applicable)
5a Name
5b Business name
(if applicable)
5c Street address
5d City, state, zip
5e Telephone no
5f Fax no
5g Email address
Page 2 of 10

B. Project Information and Prior Project History
1.
Property Identification
1a
Property identification no (tax PIN or parcel ID)�
1b
Site coordinates (in decimal degrees) I
Latitude Longitude
1c
Property size e S
acres
2.
Surface Waters
2a
Name of nearest body of water to proposed project
t'
2b
Water Quality Classification of nearest receiving water
2c
River basin
3.
Project Description
3a
Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application
cJv bf a normal A i ✓er- 60-MOM � Aed P\rc
3b
List the total estimated acreage of all existing wetlands on the property 0
3c
List the total estimated linear feet of all existing streams (intermittent and perennial) on the property
3d
Explain the purpose of the proposed project
Rem0rf A "Teed
3e
Describe the overall project in detail, including the type of equipment to be used
P(.)me frock cnd -f mc1 7& e A e f' Mv& A
4.
Jurisdictional Determinations
4a
Have jurisdictional wetland or stream determinations by the
Corps or State been requested or obtained for this property /
project (including all prior phases) in the past?
❑ Yes ❑ No Rr Unknown
Comments
4b
If the Corps made the jurisdictional determination, what type
of determination was made?
❑ Preliminary ❑ Final
4c
If yes, who delineated the jurisdictional areas?
Name (if known)
Agency /Consultant Company
Other
4d
If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation
5.
Project History
5a
Have permits or certifications been requested or obtained for
this project (including all prior phases) in the past?
❑Yes EA No ❑ Unknown
5b
If yes, explain in detail according to "help file" instructions
6.
Future Project Plans
6a
Is this a phased project?
❑ Yes,] No
6b
If yes, explain
Page 3 of 10
PCN Form —Version 1 4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
la Which sections were completed below for your project (check all that apply)
❑ Wetlands ❑ Streams — tributaries ❑ Buffers Open Waters ❑ Pond Construction
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted
2a
Wetland impact
number
Permanent (P) or
Temporary T
2b
Type of impact
2c
Type of wetland
2d
Forested
2e
Type of jurisdiction
Corps (404,10) or
DWQ (401, other)
2f
Area of
impact
(acres)
W1
Choose one
Choose one
Yes /No
-
W2
Choose one
Choose one
Yes /No
W3
Choose one
Choose one
Yes /No
W4
Choose one
Choose one
Yes /No
W5
Choose one
Choose one
Yes /No
W6
Choose one
Choose one
Yes /No
2g Total Wetland Impacts-
2h Comments
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted
3a
Stream impact
number
Permanent (P) or
Temporary (T)
3b
Type of impact
3c
Stream name
3d
Perennial (PER) or
intermittent (INT)?
3e
Type of
jurisdiction
3f
Average
stream
width
(feet)
3g
Impact
length
(linear
feet)
S1
Choose one
-
S2
Choose one
-
S3
Choose one
-
S4
Choose one
-
S5
Choose one
-
S6
Choose one
-
3h Total stream and tributary impacts
31 Comments
Page 4 of 10
PCN Form — Version 1 4 January 2009

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U S then indivii ually list all open water impacts below
4a
Open water
impact number
Permanent (P) or
Temporary T
4b
Name of waterbody
(if applicable)
/ 1904 if
4c
Type of impact
4d
Waterbody
type
4e
Area of impact (acres)
01
Choose one
Choose
02
Choose one
Choose
03
Choose one
Choose
04
Choose one
Choose
4f Total open water impacts
4g Comments
5. Pond or Lake Construction
If pond or lake construction proposed, the complete the chart below
5a
Pond ID number
5b
Proposed use or
purpose of pond
5c
Wetland Impacts (acres)
5d
Stream Impacts (feet)
5e
Upland
(acres)
Flooded
Filled
Excavated
Flooded
Filled
Excavated
P1
Choose one
P2
Choose one
5f Total.
5g Comments
5h Is a dam high hazard permit required?
❑ Yes ❑ No If yes, permit ID no
51 Expected pond surface area (acres)
5t Size of pond watershed (acres)
5k Method of construction
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below If yes, then individually list all buffer impacts
below If any impacts require mitigation, then you MUST fill out Section D of this form
6a Project is in which protected basin?
❑ Neuse ❑ Tar - Pamlico ❑ Catawba [-]Randleman ❑ Other
6b
Buffer Impact
number —
Permanent (P) or
Temporary T
6c
Reason for impact
6d
Stream name
6e
Buffer
mitigation
required?
6f
Zone 1
impact
(square
feet )
6g
Zone 2
impact
(square
feet
61
Yes /No
B2
Yes /No
B3
Yes /No
B4
Yes /No
B5
Yes /No
B6
Yes /No
6h Total Buffer Impacts
61 Comments
Page 5 of 10

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a Specifically describe measures taken to avoid or minimize the proposed impacts in designing project
lb Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a Does the project require Compensatory Mitigation for
impacts to Waters of the U S or Waters of the State?
❑ Yes ❑ No
2b If yes, mitigation is required by (check all that apply)
❑ DWQ ❑ Corps
2c If yes, which mitigation option will be used for this
project?
❑ Mitigation bank
❑ Payment to in -lieu fee program
❑ Permittee Responsible Mitigation
3. Complete if Using a Mitigation Bank
3a Name of Mitigation Bank
3b Credits Purchased (attach receipt and letter)
Type Choose one
Type Choose one
Type Choose one
Quantity
Quantity
Quantity
3c Comments
4. Complete if Making a Payment to In -lieu Fee Program
4a Approval letter from in -lieu fee program is attached
❑ Yes
4b Stream mitigation requested
linear feet
4c If using stream mitigation, stream temperature
Choose one
4d Buffer mitigation requested (DWQ only)
square feet
4e Riparian wetland mitigation requested
acres
4f Non - riparian wetland mitigation requested
acres
4g Coastal (tidal) wetland mitigation requested
acres
4h Comments
5. Complete if Using a Permittee Responsible Mitigation Plan
5a If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan
Page 6 of 10
PCN Form —Version 1 4 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a Will the protect result in an impact within a protected riparian buffer that requires
buffer mitigation?
El Yes �]� No
6b If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation Calculate the
amount of mitigation required
Zone
6c
Reason for impact
6d
Total impact
(square feet)
Multiplier
6e
Required mitigation
(square feet)
Zone 1
3 (2 for Catawba)
Zone 2
1 5
6f Total buffer mitigation required
6g If buffer mitigation is required, discuss what type of mitigation is proposed (e g , payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in -lieu fee fund)
6h Comments
Page 7 of 10

E.
Stormwater Management and Diffuse Flow Plan (required by DWQ)
1.
Diffuse Flow Plan
1a
Does the protect include or is it adjacent to protected riparian buffers identified
within one of the NC Riparian Buffer Protection Rules?
❑ Yes No
lb
If yes, then is a diffuse flow plan included? If no, explain why
❑ Yes ❑ No
2.
Stormwater Management Plan
2a
What is the overall percent imperviousness of this project?
%
2b
Does this project require a Stormwater Management Plan?
❑ Yes ❑ No
2c
If this project DOES NOT require a Stormwater Management Plan, explain why
2d
If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan
2e
Who will be responsible for the review of the Stormwater Management Plan?
3.
Certified Local Government Stormwater Review
3a
In which local government's jurisdiction is this project?
3b
Which of the following locally - implemented stormwater management programs
apply (check all that apply)
❑ Phase II
❑ NSW
❑ USMP
❑ Water Supply Watershed
❑ Other
3c
Has the approved Stormwater Management Plan with proof of approval been
attached?
El Yes ❑ No
4.
DWQ Stormwater Program Review
4a
Which of the following state - implemented stormwater management programs apply
(check all that apply)
❑Coastal counties
❑HQW
❑ORW
❑Session Law 2006 -246
[-]Other
4b
Has the approved Stormwater Management Plan with proof of approval been
attached?
❑ Yes ❑ No
5.
DWQ 401 Unit Stormwater Review
5a
Does the Stormwater Management Plan meet the appropriate requirements?
❑ Yes ❑ No
5b
Have all of the 401 Unit submittal requirements been met?
❑ Yes ❑ No
Page 8 of 10
PCN Form —Version 1 4 January 2009

F. Supplementary Information
1.
Environmental Documentation (DWQ Requirement)
1a
Does the project involve an expenditure of public (federal /state /local) funds or the
❑ Yes
❑ No
use of public (federal /state) land?
lb
If you answered "yes" to the above, does the protect require preparation of an
environmental document pursuant to the requirements of the National or State
El Yes
❑ No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1 c
If you answered "yes' to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
❑ Yes
❑ No
letter)
Comments
2.
Violations (DWQ Requirement)
2a
Is the site in violation of DWQ Wetland Rules (15A NCAC 2H 0500), Isolated
Wetland Rules (15A NCAC 2H 1300), DWQ Surface Water or Wetland Standards,
El Yes
❑ No
or Riparian Buffer Rules (15A NCAC 2B 0200)?
2b
Is this an after - the -fact permit application?
❑Yes
❑ No
2c
If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s)
3.
Cumulative Impacts (DWQ Requirement)
3a
Will this project (based on past and reasonably anticipated future impacts) result in
❑ Yes
❑ No
additional development, which could impact nearby downstream water quality?
3b
If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy If you answered "no," provide a short narrative description
4.
Sewage Disposal (DWQ Requirement)
4a
Clearly detail the ultimate treatment methods and disposition (non - discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility
Page 9 of 10
PCN Form — Version 14 January 2009

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a WIII this project occur in or near an area with federally protected species or
habitat?
❑ Yes ❑ No
5b Have you checked with the USFWS concerning Endangered Species Act
impacts?
El Yes No
❑
5c If yes, indicate the USFWS Field Office you have contacted
-
5d What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
6 Essential Fish Habitat (Corps Requirement)
6a WIII this protect occur in or near an area designated as essential fish habitat?
❑ Yes ❑ No
6b What data sources did you use to determine whether your site would impact Essential Fish Habitat?
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a WIII this project occur In or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation
status (e g , National Historic Trust designation or properties significant In
North Carolina history and archaeology)?
❑ Yes ❑ No
7b What data sources did you use to determine whether your site would impact historic or archeological resources?
8. Flood Zone Designation (Corps Requirement)
8a WIII this project occur in a FEMA - designated 100 -year floodplain?
❑ Yes ❑ No
8b If yes, explain how project meets FEMA requirements
8c What source(s) did you use to make the floodplain determination?
(Jar 0) �
Applicant/Agent's Printed Name
Date
Applicant/Age s Signature
(Agent's signature is vale my if an authorization
letter from the applicant is p rovided
Page 10 of 10

I ILLP I/ t uw dll.mtdxudLd -Lora/ dLcoum[.cfm lownerIL)=02l.-) / 8-- parcel ill.
Account Buildings Land Tax Card Sketch Deeds Sales
Real Property Record
Search
Tax Bill Search
Advanced Record
Search
Tax Bill Map
Account Details for HAY SCOTT & WF HAY CAROL u.- 1,
Property Owner Owner's Mailing Address
HAY SCOTT & WF 400 COTTONWOOD CT
HAY CAROL AVON LAKE, OH 44012 -2193
- - - - - - -- -- - - - - - - - - -- - - - - - - - -- - -- -- -- -- -- - - -
Administrative Data Administrative Data
Parcel I D No 612EO32
'OLD Tax ID Legal Desc .84AC L5
'PIN 612 E 032
Owner ID 6295783
Tax District 115 - MILLER
FERRY
Land Use Code
,Land Use Desc
Neighborhood 009WF
Deed Year 2009
,Deed Bk/Pg 11371984
Plat Bk/Pg 16607
!Sales Information
Grantor
Property Location Address
'1210 CRANE VIEW RD
Valuation Information
Market
Va h 1a
Market Value - Land and all permanent
improvements, if any, effective valuation date
January 1, 2008, date of County's most recent
General Reappraisal
'Assessed 165,750
Value $
Sold Date 2009 -02 -26
Sold Amount $165,000
If Assessed Value not equal Market Value then ,
subject parcel designated as a special class
- agricultural, horticultural, or forestland and
thereby eligible for taxation on basis of
Present -Use
PI if)( 1 his PI operty Record Cal d
Data Disclaimer All data shown here is from other primary data sources and is public Information Users of this data are hereby
notified that the aforementioned public Information sources should be consulted for verification of the Information contained on
this website While efforts have been made to use the most current and accurate data, Rowan County, NC and NexGen Digital
Document Solutions assume no legal responsibility for the use of the Information contained herein
Please direct any questions or comments about the data displayed here to taxdept a rowancountync gov
This application was developed for Rowan County by NexGen Digital
Document Solutions
www ustaxdata com
ata O170SEA > CH
of 1 9/23/2014 3 52 PM i

�:Wlr
U S ARMY CORPS OF ENGINEERS
OMB APPROVAL NO 0710 -0003
APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT
EXPIRES 28 FEBRUARY 2013
33 CFR 325 The proponent agency is CECW -CO -R
Public reporting for this collection of information is estimated to average 11 hours per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information Send comments regarding
this burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to Department of Defense,
Washington Headquarters, Executive Services and Communications Directorate, Information Management Division and to the Office of Management and
Budget, Paperwork Reduction Project (0710 -0003) Respondents should be aware that notwithstanding any other provision of law, no person shall be
subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number Please DO NOT
RETURN your form to either of those addresses Completed applications must be submitted to the District Engineer having jurisdiction over the location of
the proposed activity
PRIVACY ACT STATEMENT
Authorities Rivers and Harbors Act, Section 10, 33 USC 403, Clean Water Act, Section 404, 33 USC 1344, Marine Protection, Research, and Sanctuaries
Act, Section 103, 33 USC 1413, Regulatory Programs of the Corps of Engineers, Final Rule 33 CFR 320 -332 Principal Purpose Information provided on
this form will be used in evaluating the application for a permit Routine Uses This information may be shared with the Department of Justice and other
federal, state, and local government agencies, and the public and may be made available as part of a public notice as required by Federal law Submission
of requested information is voluntary, however, if information is not provided the permit application cannot be evaluated nor can a permit be issued One set
of original drawings or good reproducible copies which show the location and character of the proposed activity must be attached to this application (see
sample drawings and /or instructions) and be submitted to the District Engineer having jurisdiction over the location of the proposed activity An application
that is not completed in full will be returned
(ITEMS 1 THRU 4 TO BE FILLED BY THE CORPS)
1 APPLICATION NO
2 FIELD OFFICE CODE
3 DATE RECEIVED
4 DATE APPLICATION COMPLETE
(ITEMS BELOW TO BE FILLED BY APPLICANT)
5 APPLICANT'S NAME
8 AUTHORIZED AGENT'S NAME AND TITLE (agent is not required)
First -Sc 0 --tA f Middle - Last - Ae l/
First - Middle - Last -
Company - /
Company -
E -mail Address -
E -mail Address -
6 APPLICANTS ADDRESS
9 AGENT'S ADDRESS
,/
Address- / 1v (f/-<h v ! ��� 1 v
Address -
City - S4�/ J �DIJr State - C Zip % Country " '
U/
City - State - Zip - Country -
7 APPLICANT'S PH NE NOs w /AREA CODE
10 AGENTS PHONE NOs w /AREA CODE
a Residence b Business c Fax
a Residence b Business c Fax
STATEMENT OF AUTHORIZATION
11 1 hereby authorize, to act in my behalf as my agent in the processing of this application and to furnish, upon request,
supplemental information in support of this permit ap lication
SIGNATURE OF&PPLICANT DATE
NAME, LOCATION, AND DESCRIPTION OF PROJECT OR ACTIVITY
12 PROJECT NAME OR TITLE (see instructions)
13 NAME OF WATERBODY, IF KNOWN (if applicable)
14 PROJECT STREET ADDRESS (if licable
applicable) )
f
R AC
�v1
Address V O Groh e- l �L✓ l�l �/
V
City - State- Zip -
/ V `
OF PROJECT
Latitude ONION
Longitude ^W
✓�l�J�vY
16 OTHER LOCATION DESCRIPTIONS, IF KNOWN (see instructions)
State Tax Parcel ID 61; F03P_ Municipality
Section - Township - _ J Range -
ENG FORM 4345, OCT 2012 PREVIOUS EDITIONS ARE OBSOLETE Page 1 of 3

17 DIRECTIONS TO THE SITE // � Y
From 1$ S T e c. i h5 ;,errl Rd '6o &&A h d 6( f O !)
(ran e Vito C.I,c/ �S�P ae / ;lo Crag e.w-ev
18 Nature of Activity (Description of project, include all features)
P e hi v U n 5 V yx rds J a r-P
PO r C.- Y►Inw do c k,
19 Protect Purpose (Describe the reason or purpose of the protect, see instructions)
USE BLOCKS 20 -23 IF DREDGED AND /OR FILL MATERIAL IS TO BE DISCHARGED
20 Reason(s) for Discharge
21 Type(s) of Material Being Discharged and the Amount of Eac Type in Cubic Yards C� {/
Type Type��/ / O Type
Amount in Cubic Yards Amount in Cu is Ya s Amount in Cubic Yards
70
22 Surface Area in Acres of Wetlands or Other Waters Filled (see instructions)
Acres Q
or
Linear Feet
23 Description of Avoidance, Minimization, and Compensation (see instructions)
ENG FORM 4345, OCT 2012 Page 2 of 3

24 Is Any Portion of the Work Already Complete? ❑Yes XNo IF YES, DESCRIBE THE COMPLETED WORK
25 Addresses of Adjoining Property Owners, Lessees, Etc , Whose Property Adjoins the Waterbody (if more than can be entered here please attach a supplemental list)
94ddress- ,23c, c"' Q'Q,'j f�
City - 'Sc A 4 S 6L r, State - t Zip - ag r Fi
b J
ddress- ( t Sib I Y ( V1Q'
City - So,,') ! s6�� �� State - Av� zip- Z I N (o
c Address -
City - State - Zip -
d Address -
City - State - Zip -
e Address -
City - State - Zip -
26 List of Other Certificates or Approvals /Denials received from other Federal, State, or Local Agencies for Work Described in This Application
AGENCY TYPE APPROVAL' IDENTIFICATION DATE APPLIED DATE APPROVED DATE DENIED
NUMBER
Would Include but Is not restricted to zoning, building, and flood plain permits
27 Application is hereby made for permit or permits to authorize the work described in this application I certify that this information in this application is
complete and accurate I further certify that I possess the authority to undertake the work described herein or am acting as the duly authorized agent of the
applicant
(i4 {C~J l
SIGNATURE O 3 APPLICANT DATEI SIGNATURE OF AGENT DATE
The Application must be signed by the person who desires to undertake the proposed activity (applicant) or It may be signed by a duly
authorized agent If the statement In block 11 has been filled out and signed
18 U S C Section 1001 provides that Whoever, In any manner within the Jurisdiction of any department or agency of the United States
knowingly and willfully falsifies, conceals, or covers up any trick, scheme, or disguises a material fact or makes any false, fictitious or
fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious or
fraudulent statements or entry, shall be fined not more than $10,000 or Imprisoned not more than five years or both
ENG FORM 4345, OCT 2012 Page 3 of 3

ComectGlS Feature Report
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r,n, nformation ves prepared from the Rowan County NC Geographic Information System Rouen County has made substantial efforts to ensure the accuracy of location and labeling information contained on this site
to the fitness of the maps for any particular purpose and neither Rouen County nor it's agents or employees shall be liable fo
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Alcoa Power Generating Inc. ('
Yadkin Division
PO Box 576
ALCOA Badin, NC 28009 -0576 USA O C 1 © 2014
_.
Application for Activity Permit for Reservoir and Shoreline °Alteration''Es�u' vG
(Excavation, Dredge, and Fill)
Print or type all information below and return to APGI, Yadkin Division, P O Box 576, Highway 740, Badin, N C 28009
SECTION ONE – BACKGROUND INFORMATION (to be completed by the applicant)
1 Full Name (adjoining property owner) C
2 Permanent Mailing Address _) < ") C / '`,v i , j
3 Local Address (if different)
4 Telephone (Business)
5 Fax No
(Permanent)
and E -mail (optional)
6 Reservoir ri ' I , i� .,-�_ T_...__._
��wnsnip
9 Subdivision ( "� 1; , - i � }- '
11 Lot No
I ` 1 en, 8 County
10 Section.
12 Tax Map h,
13 Directions to property (f necessary, use the enclosed drawing sheet to provide us a map to the site)
14 Is the shoreline along the property described above designated as a "High Cultural Probability Zone" in Yadkin's Shoreline
Management Plan (leave blank if you do not know) ❑Yes ❑ No
SECTION TWO— INFORMATION FOR RESERVOIR AND SHORELINE ALTERATION (attach the following to the application)
1 Map of the reservoir area where the excavation is
,proposed - applicant must attach a map of the area of the reservoir and adjoining
shoreline property owned by the applicant where excavation is proposed The map must clearly exhibit the area of the proposed
excavation and to what depth (contour elevation) the excavation is proposed
2 Description of the planned excavation - applicant must attach a written description of the planned excavation including an estimate
of the reservoir bottom to be modified and the amount of material to be removed from the reservoir
3. Plan for disposal of excavated material - applicant must attach a written description of their plans for disposing of the excavated
sediment No sediment maybe disposed of within the FERC project boundary (655 foot contour APGI Yadkin Datum), or on property
owned or managed by Yadkin or Alcoa
4 Resource impacts assessment - applicant must attach a brief written description of the potential impacts of the proposed excavation
activity on surrounding reservoir resources, including impacts to water quality and fish habitat If there is any vegetation growing in
or around the area of proposed excavation, it should be noted and the areas of vegetation should be photographed, and photos
included with application
5 Schedule for conducting the proposed excavation - applicant must attach a written schedule for completing the proposed excavation
6 Agency Approvals - applicant must attach copies of,written concurrence with the,proposec( excavation from the following agencies.
- (refer to Instructions for Application for Achwty Permit for-Reservoir dnd Shoreline Excavation)
U S Army Corps of Engineers
North Carolina Division of Water Quality
North Carolina Department of Cultural Resources (required in "High Cultural Probability Zones ")
7 Non - refundable permitting fee - applicant must include a check or money order made payable to APGI, Yadkin Division in the amount
of $100 00
SECTION THREE (to be completed by the applicant)
I hereby apply for a permit to perform the above - described shoreline al(eration at High Rock Reservoir I agree to abide by all applicable
requirements of Yadkin's %Shoreline Management Plan, the conditions of the Activity Permit for Reservoir and Shoreline Alteration
(Excavation, Dredge; and Fill),and other Yadkin procedures and requirements I also agree that "no work, will begin until I receive an
i
Activly Permit signed by Yadkin
Applicant's Signature
Date
Page I of 2
White Copy - Yadkin Canary Copy pY -Applicant Pink Copy -Other