20231127 Additional information

AGENT AUTHORIZATI )N FORM
PROPERTYL-E�GAI DESCRIPTION:
7t /
LOT N0. � ,? g PLAN NO. PARCEL ID: � 13 3 O
STREET ADDRES.: 5'�)2 U -•P Yee I I
Please print: I\e Q Q C
Property Owner:
Property Owner:
The undersigned, egistered property owners of the above no -ad property, do hereby authorize
eYr l l)5� ofLo�,ke 116 rmo,7n 1�(ec)q l i'L4
(Contractor / e t) (Name of coic ulting firm) J J
to act on my beh: If and take all actions necessary for the pro) ssing, issuance and acceptance of
this permit or cer fication and any and all standard and spedd conditions attached.
Property Owner's 'lddress (if different than property above):
Telephone: 4- 6--E' LAIH2
We hereby certify the above information submitted in this apr la ation is true and accurate to the
best of our knowl dge.
Authoriz Signat ire
Date: 1/3 ��
n O l-3.D oC,40Vi®�rr,a,1.
4Y
rized Si gr rature
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7. Will work be i onducted from land? ❑ From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent in pacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
Temporary in pacts in square feet:
09
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent it pacts (including back fill, excavation, rip -ap, retaining walls, etc.) in square feet:
3�5_44 V� Ca,P .
Temporary it pacts (temporary clearing, construction corridor) in square feet:
10. Please descri ie the vegetation above the normal pool lake level/ Normal Water Level and 50
feet landwar to be impacted (number of trees, for instance): 0"
11. Signature
By signing be ow, I, as the project proponent, certify to the following:
• The proje :t proponent hereby certifies that all information contained herein is true,
accurate and complete to the best of my knowledge and belief
• The proje A proponent hereby requests that the certifying authority review and take action
on this C VA 401 certification request within the a )plicable reasonable period of time
Owner/Age it's Signature 1 NC 2H .0502 f ] D ite
'Agent's sigi ature is valid rf an authorization letter from the owner is provided.
12. Please apprc (imately sketch the following informatior, on this plan and provide dimensions for
each item:
a. All pro;: )sed vegetation clearing
b. Locatio i of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Locatio i of rip rap or fill to be placed below the Dull Pond/ Normal Water Level elevation
d. Locatio i of any proposed structures such as buildings, retaining walls, docks, etc.
e. Locatio r of any excavation or dredging below tho Full Pond/ Normal Water Level
elevath n
FORM: SSGP 09-2020 Page 3 of 5

1
Full Pond/ Normal Wa' sr Level
Shoreline
Plan View
u I Pond% Normal
Lake
(At Full Pond/ Normal Va ater Level)
o Oar
2 ft. �1W h.
ac Bt—N dW
• A necnsery
E
Plan View
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� M0 II�1
Lake
V3 Wl roiw xanww L..di Existing Dock
/Wft.7ft
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FORM: SSGP 09-2020 1 Page 4 of 5