20071692 Ver 1_More Info Received_20071015

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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.
Applications should be sent to:
Division of Water Quality Wetlands Unit
1650 Mail Service Center ~~
Raleigh, NC 27699-1650 ~ ~ ~ ~~
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Applicant Information ~E'ngryD~pHQSr ~«y
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1. Owner/Applicant Information
Name: Hudson K Bates
Mailing Address: 9 Chantilly Place
Durham, NC 27707
Telephone Number: 919-313-7593 Fax Number: 919-544-7724
E-mail Address: hbates(anipera.org
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:
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

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your project. Also, seethe example below for guidance. Both the vicinity map and
site plan must inchide a scale and north arrow: The footprints of all buildings,
impervious surfaces, or other facilities must be included.
1. Location
County: Person Nearest Town• Roxboro
Subdivision mane or site address (include phase/lot number): t)r,dc Pout
Directions to site please include road numbers, landmarks, etc. (This is not
necessary if as adequate vicinity snap is included): see mao
2. Describe the existing land use or condition of the site at the time of this
applic~ion:
vacant b~ldlnp dot w11h a~ baY boat dock
3. Property size {acres): 1.35 acxes
4. Nearest body of water {stream/river/sound/ocean/lake) ~roo take
5. Describe the purpose of the proposcd work: RepleNsh a.r~t shorNine riprap and stadlze ahorelkre erosion a,
areas where riprap was not oripiragy insta~d
6. List the type of equipment to be used to construct the project: ~ ~ ~.cc~'
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls,
etc.) below the normal pool lake level in square feet or acres:
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8. a. Amount of impact (including all cleaning, back fill, excavation, rip rap,
retaining walls, etc.) above the normal pool lake level and 50 feet land ward in
square feet or acres:
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b. PJpase describe vegetation above the normal pool lake level and 50 feet land-
w to b~acted (number of trees for instance): ~~ ,~
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(Agent's signature is valid only if an authorization letter from the applicant is provided.)