20141101 Ver 1_401 Application_20141016

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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 () copies of this application and supporting
information as well as a non-refundable application fee to the Division of Water Quality of $240.00
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
Raleigh, NC 27699-1650
I. Applicant Information
1. Owner /Applicant Information
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Name:
Mailing Address:
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Telephone Number. �71q 73 0 -5 9O2__ Fax Number: '
E -mail Address: Ne_0 "-2 ,re �G .� Ac 'qA /j°i 61 op �• �i. - �d�} --
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:
H. 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.
RECEIVED
OCT 16 2014
DENR -LAND QUALITY
STORMWATER PERMITTING

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1. Location
County: _e150iI Nearest Town:
Subdivision name name or site address (include phase/lot number): Ld
Directions to site please include road number-s, landmarks, etc. (This is not necessary if an adequate
vicinity map is included): �TyYr- Fd �. h oZv G�w y j"7 &�d7'_
2. Describe the existing land use or condition of the site at the time of this application:
3. Property size (acres): 9-4 0'� 1--e- S
4. Nearest body of water ( stream /river /sound/ocean/lake): 6-, t4-A-e.
5 Describe the purpose of the proposed work: r
6. List the type of equipment to be used to construct the project: _s ��� S h--e— --
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls, etc.) below the
normal pool lake level in square feet or acres: `f 601 >,— G
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:
Z/11-v d `o,c (,
8.b. Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance):
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Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

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Personal Account Information Redacted