20230538 Christopher Bell page 3 shoreline app

7. Will work be conducted from land? ❑ From water?
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permar ent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
Tempor impacts in square feet:
9. Total amount of impacts above the normal pool lake level /Normal Water Level and 50 feet
land -ward
Perm ent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
v� ill �- C p V. cuf )
Te � rary impacts (temporary clearing, construction corridor) in square feet:
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50
feet landward to be impacted (number of trees, for instance):
11. Signature
By signing below, I, as the project proponent, certify to the following:
• The project proponent hereby certifies that all information contained herein is true,
accurate, and complete to the best of my knowledge and belief
• The project proponent hereby requests that the certifying authority review and take action
on this CWA 401 certification request wn the applicable reasonable period of time
Owner/Agent's Signature` [15A NCAC 02H .0502(f)]
Date
*Agent's signature is valid only if an authorization letter from the owner is provided.
12. Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level
elevation
FORM: SSGP 09-2020 Page 3 of S