20160934 Ver 1_401 Application_20160916

September 21, 2016
Division of Water Quality Wetland Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
2 O 1 60 934
My signature below authorizes Sonny Tyson of Sonny's Construction to act as my agent to file the
abbreviated application form for applying for a 401 Water Quality Certification to impact
FERC (Federal Energy Regulatory Commission) regulated lake shore or bottom under the
U.S. Army corps of Engineers Permit GP 30.
Date
Dan Samples
10735 Willow Oak Rd
Norwood, NC 28128

The following is an abbreviated application form for those applying for a 401Water
Quality 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 $240.00 for
impacts of to lake bottom of less than 1 acre and $475.00 for impacts to lake bottom
of greater or equal to 1 acre.
Applications should be sent to:
Division of Water Quality Wetland Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
I. Applicant Information
1. Owner/Applicant Information
Name: Dan Samples Mailing Address
Site Address 10735 Willow Oak Rd
Norwood, NC 28128
Telephone Number: [phone] Alt Number
E-mail address:
2. Agent Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent has signatory authority for the owner/applicant.)
Name: _ Sonny Tyson
Company Affilaition Sonny's Construction
Mailing Address: 186 Vineyard Road
Norwood, NC 28128
Telephone Number: [phone] Fax Number
E-mail address: son nyCaD-sonnysconstruction.com
II. Project Information
Attach a vicinity map clearly showing the location of the property with respect to
local landmarks such as towns, rivers, and roads. Also provide a detailed site
plan showing property boundaries and development plans in relation to
surrounding properties. You may use the diagram below to make a hand 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.

1. Location
County: Stanly Nearest town: Norwood, NC
Subdivision name or site address(include phase/lot number) _
10735 WillowOak Road Portions of Lots 83,84 & 85 Turner Beach
Directions to site please include road numbers, landmarks,etc (This is not
Residential home with grass lawn and natural area ( See Uicltided nutp)
In Norwood traveling south, Turn left on Fork Road
Left on Piney Point Road
Left on Willow Oak, destination will be on the left
2. Describe the existing land use of the site at the time of this
application:
Single family residence
3. Property size (acres) Approx .30 acres
4. Nearest body of water(stream/river/sound/ocean/lake): Lake Tillery
5. Describe the purpose of the proposed work:
Replace portion seawall and install rip rap
6. List the type of equipment to be used to construct the project:
Excavation equipment /Carpenter tools
7. Amount of impact (including all excavation, backfill, rip rap, reatining walls,
etc.) below the normal lake pool level in square feet or acres:
400 Square feet
8. a.Amount of impact (including all clearing, backfill, excavation rip rap,
reatianing walls, etc.) above the normal pool lake level and 50 feet landward in
square feet or acres:
500 Sauare feet
b. Please describe vegetation above the normal pool lake level and 50 feet land-
ward to be impacted(number of trees for instance): _..
Natural area covered with grass and vegetation.
No vegetation to be affected.
-- September 21, 2016
Applicant/Agents's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided)

Lake (Full Pond)
Remove and replace existing seawall
100 feet of rip -rap to be
installed on shoreline
aprox 50 feet of seawall
2 to 1 slope
Approx 500sq ft
to be replaced
Install rip rap on lake
side, 2 to 1 slope
Approx 400 sq ft
%X
Full Pond
Shoreline
(Lake Tillery)
Please approximately sketch the following information on this plan
(please provide dimensions for each item, such as 10 ft x 100 ft)
1) All proposed vegetation clearing (provide dimensions)
2)Location of rip rap or fill to be placed above the full pond elevation
3)Location of rip rap or fill to be placed below the full pond elevation
4)The location of any proposed structures such as buildings, retaining
walls, docks, etc
5)The location of any evacuation or dredging below the Full Pond
elevation.
6)Location of construction access corriders.

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10735 Willow Oak Rd
Norwood, NC 28128

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10735 Willow Oak Rd
Norwood, NC 28128
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[n Norwood traveling south, Turn left on Fork Road
Left on Piney Point Road
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