20170008 Ver 1_Shoreline Stabilization_20161230

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The following is an abbreviated application form for those 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 GP30. This Application cannot be used
for wetland or stream impacts. Please provide five (5) 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 to lake bottom of less than 1 acre and $570.00 for impacts to lake bottom of greater or
equal to 1 acre.
Applications should be sent to:
Division of Water Quality 401 Oversight/Express Review Permitti
1650 Mail Service Center
Raleigh, NC 27699-1650 $ PAID
I. Applicant Information
1. Owner/Applicant Informationn
Name: G IC -14 n ))e_;=1 rS 6 �1
D
DEC 3 0 2016
DEQ -WATER RE OURCES
401 & BUFFER PERMITTING
Mailing Address: Dr-
))e-/7
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))e-r! "-r-, ?_ S -o -,-> 7
Telephone Number: 9/0 - 920 S Z ?5 7 Fax 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: ,()A ✓r°
Company Affiliation: 2�L,6o Q� �acl� �► I� ss2
Mailing Address: SSS (� //� ��s�,-, Q�l_ �%�rsLJ, /1Q A/(f 2g I i 7
Telephone Number: -20q - & S" 3 z/ 79' Fax Number:
E-mail Address: Qk�vAC�_' f)V- rr� o,-•,nc�� r z„,.i
H. 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
planmust include -a scale and north_ -arrow. The footprints of -all buildings, impervious -surfaces, or..other
facilities must be included.

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1. Location /
County: L A G './N Nearest Town:
Subdivision name or site address (include phase/lot number): L .11,eumd YJA 1 LA 35j
Directions to site please include road numbers, landmarks, etc. (This is not necessary if an adequate
vicinity map is included): v /i - /l/ - /Z, 2� 2j -) z, n ale
2. Describe the existing land use or condition of the site at the time of this application:
3. Property size (acres): . G q c\
4. Nearest body of water (stream/river/sound/ocean
/lake): A -A- Ax,_t , A-"
5. Describe the purpose of the proposed work: ✓�t�� - Q g ;f ,,y ��yZ4 r7 GeV
6. List the type of equipment to be used to construct the project:
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls, etc.) below the
normal pool lake level in square feet or acres:
f 7? l� l._ A-
8 -a. Amount of impact (including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
above the normal pool lake level and 50 feet land -ward in square feet or acres:
26 o sq_ . P�
8.b. Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance):
Applicant/Agent's Signature _ - - Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

Google Ear"' L feet m200
meters 60