smith.pdf

7. Will work be conducted from land? ❑ From water?
8. Total amount of impacts below the normal pool lake level / Normallater Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
ry impacts in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
back fill, excavation, rip rap, retaining walls, etc.) in square feet:
porary impacts (temporary clearing, construction corridor) in square feet:
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50
to be impacted (number of trees, for instance):
11. Signature
By signing below, 1, 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 within the applicable reasonable period of time
Owner/Agent's Signature' [' A(I ] 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 5