20010034 Ver 1_Application_20000922

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G. APPLICANT'S NAME
1'~ 1 N G ~s ~iR taN -T ~'c., u 8
_ 8. APPLICANTnnS ADDRESS
COT E KoS~ G1R.ov p; A"1TN i SO[., ~CSL
!05(Gic.c.~?sp,~ ~7-
y~v~e.c. ^~!~ 28301
a. Rasldance
b. Dualnesa C~~p, 3Z3.3yoo
r v uc rrLLeiJ tiY
8
S
AVTHOR(ZED A ENT'S NAME AND TITLE ran apanr la nor ~ooulradl
e~+anuar ~OC.u s
~FGu~Y?r-roey G~oNSvLY~NT
AGENT'$ ADDRESS
13 8 G-Qa~ ~o~sy- ~,e i vE
e. Residence
b. Businea9 C~~~ _3CIZ_~g33
--
STATEMENT ~F AUTHORIZATION
1 hereby euthorl2e,
furnish, upon request, ou to act in my behalf as my agent in the processing of thls appllcation and to
pp omuntal Information in support of this permit application.
APPLICANT'S SIGNATURE / ....~... _ ~~„
DATE
NAh1E, LOCATION AND DESCRIPTION OF PROJECT OR ACTIVITY
t 2. PROJECT NAME OR TITLE r~.. h:h„~t~,n,l
CO wtp[r~-rtoN p ~
F I{fHIG S GRwivr- ~oLF finl~ C'oUnrna~( ~a[~ e3
3. NAME OF WATER80DY,1F KNOWN r/Y~pNk.r,~~J
/ZIAvTS1K~{ DF CagrZVS~~s +~~ ~4. PROJECT STREET ADDRESSrNaaollnwl./
c>aP~ ~~,~ r~~~ 3ws,N
t5. frOCATIONOFPROJECT Ur S, f,#CVy ~{U~ f~01Q,•~-~
~~~~rzc.wNa !~. C'.~ ~i4Y~frl~v~u.~, N, C' ,
STATE
10. OTHER LOCATION DESCRIPTIONS, Ir KNOtiVN, ryas/iulrvcrlonrJ "'~"
17. DIRECTIONS TO THE SITE

S~?.21'20i)p 10:ti~1 9_025i4v^25 JS:.ED t•JILi~1I?1GiViv ro- t: ..,~ ~
P~Ji. ~ . .i 1. ..~ V 4J
18. Nature of Activity to+.~~a,,, u/po~aor, rnrruda agfaarwocJ
(~oNSTRUG.T WL~'C.jgND C2oS5!/vG -~ -T-E.~2~- R~m-aINI~1c i~ll6f-f GROUND A12~5
~4MD ~f2oY-D>: F®2 /NC-D~TlTAL w~-~,}q~p D1sYVR8A~1C~ '7'0 ~LC~w
Go/,15TRveYte~! of ~'oun rnuer(-F)ar>1tt..`{ 8~1t.i~-NGS ~s,.~ /1/0. ~)
19. Pro)OCt PUrpOaa mwcri0l rM noon or purpp+r or fA~ po/+er, +++4ahucflonoJ
Pt2oVIDE 12E'$rD~/'t'tpL ~-}DUS1N6
ND
~~~ ~~
20. Reason(s) for Discharge - - ^~'~~~ ,,______._ _
~t~ PR DV r DE' STT2~'E'T ~ cc.;E5 s Tb ~N/Gf! Gr~U~t D 4a12t~45 ~si-rt°3 /Glos. z ~ q`> _~J~.~:,~ ,~ C
P1RDVIDS 1~ct2 GONS`~ZU[.Y10N eF ~j/ ~'JfULTI ~~'I8lfJ/Ly 13L1/LDlKGS f/.SlT~ Jed. 3)
21. Typafal of Matati9l$eing plaehargod and tho Amount of Each Type In Cubic Yards '~ S ~ ,}- [Qq6
~:~~~~
~riNO .:' ~~'~ ~j
-' „ t
22. Surtoco Aroa In Acres of Wetlands or Other Waters Filled rr++lnpauraasl
l o l l `~C~~r~. L ~ ~'1('~~.~~
~~
23. Is Any Portion of the Work Already Completol Yes No IF YES, DESCRIBE THE COMPL[TCD WORK `~~-
24. Addrosaea of Adjoining Property Owners, Lessees, Etc., Whose Property Adjoins tho Watorbody pf moro titan con ba ontored hers,
plonse attach a supplomontal Ilst}.
.,
~N Tr -? E" ~'rf"E ! 5 w / T1d /ti/ /~ !~!G s ~',~ q ,u.r.... F~QOp~7'L.,,~
26. List of Other Cartificetlons or Approvals/Denials Rviceivod from othor Fedoral, Stoto or Local Agencies for Work Dsscrlbed in Tltis Application,
AGENCY TYPE'APPROYAL• IDENTIFICATION NUMBI=Fi DATE APPLIED DATE .APPROVt;D DATE DENIED
/51 C~ X111 ~f o 1 W ~G 9'G O +-E ~ g 5~9~9G ~ ~131`~G
'Would Include but is not restricted to zoning, building and flood plain permits
28. Application la hareby mado for o pormlt or permits to authorize the work described In this application. I certify that the lnformotlon In this u
application w complete and aCCUrate. I further certify shpt I pos8eaa th0 authority to urtdorcako tho wor described herein or am acting as the
duly authorized agont of the applicant.
. ,
~ ~, ZDo ~
SIGNATURE OF APP.(.IpANT p,ATE SIGNATURE OF AGENT nnTc
the application must be signed by the person who desires to undertake the proposed activity (applicant) or it ,-nay be algn.ad by a duly
authorized spent If the atatemant in block 11 has boon flllud out and signed.
18 U,S,C. Section 1001 provid5e thAt; Whoavpr, in ony manner within ttia jurisdiction of any dopartmont or agency of tho Urltod States
knowingly and willfully falsifies, conceals, or covers up any trick, schema, or disguises a material factor mykea any {also, iictitlous or
fraudulent statements or representations ormakes or uses any fslsa writing or document knowing same to contain any false, fictitious or
fraudulent atatamanta or ontry, aholl bo ilnctd not moro than S 10,000 or Imprisoned not mare than flue years or both.

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KING'S G ~ ~,_-_„11;;`: -
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THE ROSE GROUP, INC. - 11j1 ' '1 \"1 '/
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EN INEER$• - PLANNERS - $URVEYOR$ r / 1 `
FAYEREV1lLE N.C, t, .• 1'

~ WETLAND LIlVIITS ~
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6500 SgFt Area to be Filled
for Ridgeway Drive Extension
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SITE No.2
RIDGEWAY DRIVE EXTENSION
HING'S GRANT CLUB ~ "
104 GILLESPIE STREET
FAYETTEVII.,LE, NC 28301
MARCH 2001
Sheet 1 of 1
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. ' . ' , ' . ' . ~ , ' ~~~ .a ;~ ~-~`~~ ~ ~ WII,LIWOOD ROAD EXTENSION
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i • ~ + ~ + + • ' + ~ •~ ~ ~~ ~ , ~ ~ ~ : ; .. ~` ~• ~ : ~. ~~~: IdNG' S GRANT CLUB
... 104 GII,LESPIE STREET
FAyETTEVII,LE, NC 28301
MARCH 2001
Sheet 1 of 2 ~ ~~
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,~~ 4000 SgFt Area to be Filled •
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I ~`.~'_ `' II WETLANDS ~ ~ ;
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111 m
Scale:l"=40' S
SITE No. 9
WILLIWOOD ROAD EXTENSION
HING'S GRANT CLUB
104 GILLESPIE STREET
FAYETTEVII..LE, NC 28301
MARCH 2001 ~~~; j
Sheet 2 of 2 `~~-'~i ~~~