20150012 Ver 1_Shoreline Stabilization_20150105

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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 five (5) 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 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
EDENR--TA_LE�5R I. Applicant Informatio n 5 2015 1 Owner /Applicant Information RESOURCr S
y� ,/ v L � l ERMITTING
Name. �i V e"1
Mailing Address- �rGr��'J
Telephone Number: a 6'*09 nFax Number: 02.6- &01?) -0 f5
E -mail Address: Cje V� ck✓ LYu� SVi A5Soc4k" . Gz, rv,
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.
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

Location
County Nearest Town:
Subdivision name or Bite address (include phase/lot number)
WA-
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 application:
3 Property size (acres).
4 Nearest body of water (stream/nver /sound/ocean/lake): (_J ✓�t_
5 Describe the purpose of the proposed work- -6 J . � C"D oe,�, w M
t
co�ra� -e ••i'wci�• w
6 List the type of equipment to be used to construct the project: Irm -1.0 ot-�� • w��� w
h Q-O-XcQ 40 M. te_ i yr fo-e �
7. Amount of impact (including all excavation, backfill, np rap, retaining walls, etc.) below the
normal pool lake level in square feet or acres. Aov\Pr
8 a Amount of impact (including all clearing, back fill, excavation, np 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 normal pool lake level and 50 feet landward to be impacted
(number of trees for instance). iiu
Signature
Date
(Agent's srgnaYure is valid only if an authorization letter from the applicant is provided.)

Please approximately stretch the following information on this plan
(please provide dftnensions for each item, such as i6 #t. x joe ft):
d) AS proposed vegetation clearing (provide dimensions)
2) Location of rip rap "fill to be placed above the Fall Road, elevation
3) Location of rip rap or fit to be placed below the 'Full Pond elevation
4) The location of any proposed structures such as buildings, retaining
irrallsg docks, etc.
The location of any excavation or edging below the Fu_ ii Rand
elevation.
6) Location of construction access corridors.

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