20061681 Ver 2_Application_20070112

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The following is an abbreviated application form for those applying fora 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 seven (7) copies of this application and supporting information as well as a
non-refundable application fee to the Division of Water Quality of $200.00 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 Wetlands Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
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~J Applicant Information
~~ Owner/Applicant Informati~
Name: ~qn C' ~`fiGz S ~
M~~.ttling Address: i ~ ~ ~ C'
DENR -WATER QUALITY
WETLANDS AIJD STQRMWATER BRANCH
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Telephone Number: ~~ c~ - ~ ~~ " Z ~ Z~ Fax Number: ~1 t ~~ ~ 7 ~ ~~ ~~ ~
E-mail Address: r; .c~.~ ~n ~ s` ~'- ~ ~- ~~ ~~ z ~ ° ~'"`
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:
Company Affiliation: ,... _.,.
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
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

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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:~~('c+, I~ ~li Nearest Town:
Subdivision name or site address {include phase/lot number):
Directions to site please include road numbers, 1 dmarks, e~G~ Th' ~~s not
necessary if an adequate vicinity map is included)., ~. ®1~' ~T ~.
2. Describe
6. List the type of equipment to be used to construct the project: /~Un.c,~
3. Property size (acres): r O U `^C.~S
4. Nearest body of water (stream/river/sound/ocean/lake}:
5. Describe the purpose of the proposed work:- ~~~~5 7~ LA~(~ -
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls,
etc.) below the normal pool lake level in square feet or acres: NU ~' ~~'
a. Amount of impact (including all
retaining walls, etc.) above the normal
square feet or acres: /VG ~ i~T ~
clearing, back fill, excavation, rip rap,
Wool lake level and 50 feet land-ward in
b. Please describe vegetation above the normal pool lake level and 50 feet land-
ward to be impacted (number of trees far instance): ~,xC

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use or condition of the site at the tip of this
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Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
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