20020957 Ver 2_Application_20090821

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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: s P A i
Division of Water Quality 401 Oversight/Express Review Permitting _ , , ?-
1650 Mail Service Center D''l
Raleigh, NC 27699-1650
AJIi?. I 2009
1. Applicant Information
DENk - WATER QUALITY
WETLANDS AND STORNWATER BRANCFI
1. Owner/Applicant Information
Name:
Mailint
Telephone Number: 70?(- , / l Fax Number:
E-mail Address: ?C-0? t5-`
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:
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 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.

Fax Number:
1. Location
County: `?. Nearest Town: f,
Subdivision name or site address (include phase/lot number): 0 j2 N c= 9-
Directions to site please include road numbers, landmarks, etc. (This is not necessary if an adequate
vicinity map is included): 14 ,,3,1i S 5 0L-J h 1y o Q to c, o
1 A -
2. Describe the existing land use or condition of the site at the time of this application: i2Cs
3. Property size (acres): Y ,-2- A i g2
4. Nearest body of water (stream/river/sound/ocean/lake): !_ ,--K e- I J (t_-4--
14
5. Describe the purpose of the proposed work: S o 42 t F. , A J S } b ; •p W
6. List the type of equipment to be used to construct the project: ?yb c ,-HI' S IC;ce SfL- e-P-)
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 ?p -F f
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 " square feet or acres:
?b? 5c
8.b. Please describe vegetation above the normal pool lake level and 50 feet landward to be impacted
(number of trees for instance): 0 o f-OZ-0 t - -S ? n b E
f? 11 rc L Cam a?/? c? S S
2Z) - d
Applicant/Agend
(Agent's signature
Date
only if an authorization letter from the applicant is provided.)
S01 North Carolina Department of Cultural Resources
State Historic Preservation Office
Peter B. Sandbeck, Administrator
Beverly Eaves Perdue, Governor Office of Archives and History
Linda A. Carlisle, Secretary Division of Historical Resources
Jeffrey J. Crow, Deputy Secretary David Brook, Director
ER 09-1840
Received August 3, 2009
Due August 17, 2009
NATIONWIDE PERMIT REVIEW
APPLICANT: Nancy Jane Hartsell
PO Box 632
Norwood, NC 28128
Project Location: Stanly County
Proposed Project: Soil Disturbance, 10715 Willow Oak Road, Norwood, Lake Tillery
The North Carolina State Historic Preservation Office has received the application for
the above project and our comments are noted below.
Additional information is needed (maps, photographs, other).
No comment.
We have reviewed the requested information and have no comment.
Signed &' 5Ho'D
..Le-Renee Gledhill -Earley
`ll Environmental Review Coordinator
State Historic Preservation Office
4617 Mail Service Center
Raleigh, NC 27699-4617
Phone - 919/807-6579
FAX - 919/807-6599
Date q tt i u9
Location: 109 East Jones Street, Raleigh NC 27601 Mailing Address: 4617 Mail Service Center, Raleigh NC 27699-4617 Telephone/Fax: [phone]-6599

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Lake (Full Pond)
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Phase approx * sketch the f*VW** g ifftf 01 coon on this plan
x 180 ft):
(please Provide dirrarnsions for each K
pmvWle om such as 10 ft.
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1) m proposed ver tation claw*q (
Z) 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 FUN Pond ekwation
4) The location of any proposed structures such as bui rP, retak*V
waft, docks, etc.
5) The location of any excavation or *W&V below the Full Pond
61 Location of construction access corridors.
Full Pond
Shoreline
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wood, NC 28128-8496
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Dir ections from A to E'.
® t Stem out gong NORTHEAST toward N KENDALL STW-1927. 0.2 nu
2 Tum RIGHT onto N KENDALL STINC-1927. 02 mi
3. Turn LEFT onto NC-19671OL D RD. 0.2 ft
+. 4'. NC-19971OLD RD becomes COLLINS AVE. 0.2 mi
_.
R6r 5 Turn RIGHT onto US-62 EIN NOR WOOD AVE- Conlnue to follow US-52 2.3 mi
. E
s. Turn LEFT onto NC-731. 0.8 Cry
Turn LEFT onto FORK RDMC-1786. 0.2 mb
S. Turn RIGHT onto PINEY POINT RUNC-1768. 0.6 mi
e: KeaP RIGHT at Core fork to writnue on PINEY POINT ROMG 1768. 0.5 mi
10- Turn LEFT onto WILLOW OAK RD. 07 fnl
,., . , Turn RIGHT to stay on WILLOW OAK RD. 0.2 mi
?. 10715 WILLOW OAK RD s on the LEFT. 0.0 1,111
l ota. 'i rave; Eslifnwe5: Time: 16 m,nt.!t*s ..: 106 m.les , .. i' Calculate
As nVft reserved. Use subject to LberoaC-opyngM Map legend
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route usabssy or expeditiousness. You asstane as rise of use. Map6ueM ant is M"Mera shalt not be fable 1. ww for