20071721 Ver 1_More Info Received_20071026

The following is an abbreviated application form for those applying fora 401 Water
Quslitl 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 S200.00 for
impacts of to lake bottom of less than 1 acre and 5475.00 for impacts to lake bottom
of greater or equal to f acre.
Applications should be sent to:
Division oCVVater Quality R'etlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
L Applicant Information '
1. OwncriApplicatu Infortnatiott~ ~\\ /-
Nanrc. ~/`~ L r~
Maihna Address:__ _. _._--____._
_. _____.
l clephone Number: ___- __.__ Fax tvumber:
F-r:7:ail Address: _ - -_ _ -- _.. _ __ _
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~. Agent Information lA sirmed and dated copy of the .Agent Authorization letter
must be attached if the Agent has siEnuatory authority fur the ownzrapp}icant.)
Name: - -
--- -
CompanyAftiliatinn __, ___ __- _ _ _ __-
(Lt3111I1g AddreSS:_____ ____ -.--_-.- '-._ _.__._.. __._. __...
"Telephone Number:...
f:-mail Address: _ _
IL Project Information
Attach a vicinity map clearly showing the location of the property with respect to
Luca} landmarks such as towns, rivers, and road_c. Also provide a detailed site
plan showing property boundaries and development plans in relation to
suaaundinti properties. You may use the diagram below to make a hand sketch of
Fax Numbcr:-
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N~V ~ % 2001
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