20071974 Ver 1_Application_20071126

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The following is an abbreviated application form for those applying for a 401 Water
Quality Certit`ication 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-refandabk application fee to the Division of 'Water Quality of $200.00 for
impacts of to lake bottom of less than 1 acre and $475.0(1 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 27599-1650
I. Applicant Information
1. Owner/Applicant Infor anon ~ ~ / R ~~
Name: ~ ~ h
Mailing Address:- ~ Q~~o ~ ~~~~
__.. n.__ __ 1..
Q~~ 1~
~~~ ~ 1 2007
~~EYV~(- VVA7Ef~ C~UAL1Tl'
V~£TIAND,4!u~'D STOf?M!."!;ATER 9RANCN
f`~~.ll , ,~s
Telephone Number. e - - 2 ~ ! Fax Number:
E-mail Address- ~ r 1'G .
2. Agent Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent had signatory authority for the owner/applicant.)
Company Affiliation: '
Mailing Address•
Telephone Number: Fax Number.
E-mail Address:
II. Project Information
Attach a vicinity map cleazly showing the location of the property with respect to
local landmarks such as towns, rivers, and roads. Also provide a detailed site
plan sowing property boundaries and development plans in relation to
surrouing properties. You may use the diagram below to make a mad 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 lend itlc
County:_ mo Nearest Town: l+'If ~~
Subdivision namc or site ad ss (include phase/lot number): llc t. ~~ ~` o
Directions to site please include-road numbers, landmarks, etc. is is not
necessary if an adequate vic i map is included):
See ~c%d /~ pia. ~ ••~
2. Describe the exiting land use or condition l the ite at the tim ~r

3. Property size (acres): 3 r+e S
~e~ ~/cr
4. Nearest body of water (streamkiver~sound/ocean~lake);~°~ ~l~t..-•N -
5
b.
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls,
etc.) below the normal pool lake level in square feet or acres:.~~5. SQL > X l r!6
8. a. Amount of impact (including all clearing, back fill, excavation, rip rap,
retaining walls, etc.) above the normal pool lake level and SO feet land-ward. in
squarc fcct or acres: /Ds~o
b. Please describe vegetation above the normal pool lake level and 50 feet lan
ward to be impacted (n ber of trees for instance):~,.t_~~
715 ~ // / i ruS ~ ~ ~
' - Date
App ' an Agent's Signature
{Agent's signature is valid only if an authorization letter from the applicant is provided.)
gist the type of equipment to be used to construct the proj~ :_ ~~; '-E' °~r`'r '

,Map of Tillery Tradition, 214 Lillys Bridge Rd Mt Crilead, NC by MapQuest#north Page 1 of 1
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,Map of Tillery Tradition, 214 Lillys Bridge Rd Mt Gilead, NC by MapQuest Page 1 of 1
Sorry! When printing directly from the browser your map may be inmmectly cropped. To print the
J entire map, try licking the "Printer-Friendly" link a[ the top of your results page.
~~~~~~~~
Tillery Tradition:
910-439-5146
214 Lillys Bridge Rd
Mt Gilead, NC 27306, US
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~ entire map, try licking the "Printer-Friendly" link at the [Op of your results page.
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All riah[s re~rved Use Subiert to UcEnse/Coovriaht
This map is infortna[ional only. No representation is made or warranty given as to its content. User assumes all risk of use. MapQuest and its suppliers assume no responsibility
for any loss or delay resulting from such use.

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OWNER: 1HE TILLERY TRADITION. INC.
DEE6 REFERENCE: D,B. 343. PG. 453
D.B. 390. PG. 189
TA% PIN NUMBER: 6576.04-BI-8945
REVISIONS: 10/16/00-CHANGE LOT MUMSERS
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