20190968 Ver 1_401 Application_20190719

FRED BAIRD BLACKLEY, ASLA
LANDSCAPE ARCHITECT J
UT SR SiELBY504 SONORTHHDEKALBCAROLINT A E28150 \I -(.1\,
(704)484- 731 1-) - v \ °\
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Transmittal ()i
To: _IIV_CYINH___ Attn:
Dw ,Et: _
1• b ! -u' d °l e- Project No: I ., 1 -
�'." - g-*ItS(j Date: 1 l
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For: APPROVAL p INFORMATION RECORD REQUEST REVIEW )c) COMMENT USE
Remarks:
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Copy To: VIA. By:
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Via: US MAIL AIRBORNE PICK UP UPS FAX HAND DELIVER OTHER

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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 seven (7) copies of this application and supporting information as well as a
non-refundable application fee to the Division of Water Quality of $3 OD for -7- (-)
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.
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Applications should be sent to:
Division of Water Quality Wetlands Unit •
1650 Mail Service Center
Raleigh, NC 27699-1650
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I. Applicant Information
1. Owner/Applicant ation
Name: h i I yn'C., Iv kiV
Mailing Address: 1Oy For, pc S
SAfrishi 44, co
Telephone Number: (f g�i—` `f f ' Fax Number: �-'
E-mail Address: L,1 IAA.) c �3v�(,�►
2. Agent Information (A signed and dated copy of the Agent Authorization letter
must be attached if the ent 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 14 ,
County: Nearest Town: C/ ilk) S Why
Subdivision name or site address (include phase/lot number):
Directions to site please include road numbers, landmar s, etc. (This is not
neces ary if An adequate vicinity map is i chid d): lO L�,I -- CLwijuJL
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- s z-k- i �^ . li 3��
2. Describe the existing land use or conditioni pf the site at the time of this
application: l v7 i8, 1'1't Cu m---
3. 0 Property size (acres): N , wti JQ-( C4 / 1 c 41110
p � �. C(C
4. Nearest body of water(stream/river/sound/ocean/lake): P'VerCi5 (/64)(1d-
..
5. Describe th,p pu ose of the proposed work: II n1
1tti ' J r i t s 1 tJ . l f'L ,S.
6. List thy typq of quipment o be 9sed to cons et the project:project:X.I n 1 Traxiti-- IAA et_
7. Amount of impact (including all excavation, backfill, rip rap, retaining walls,
etc.)bbJ. w the normal pool lake level in square feet or acres: ) 0 )Z3 ' 50 15 f
Pal 4 1000 cr--
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: I, 'I yc 5 = Frff-
gavy
4 tea 5f -
b. Please describe vegetation above the normal pool lake level and 50 feet lan
ward to be impacted (nu ber of trees for in tance): N ) 0 *--ve.€ , by
v'e-(` ( i Q111112 / V t kn t ion-esi)
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Applicant/Agent's Signa Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)

Lake (Full Pond)
Full Pond
Shoreline
co,e rteitiN 611
‘reA \ \
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Please approximately sketch the following information on this plan
(please provide dimensions for eachitem, such as 10 ft. x 100 ft)
J1) All proposed vegetation clearing (provide dimens ns)
Location of rip rap Or fill to be placed above the Full Pond elevation
Locationrap of rip or fill to be placed below the Full Pond elevation I c.oir
The location of any proposed structures such as buildings, retaining
walls, docks, etc,
j\rnfThe location of any excavation or dredging below the Full Pond
, elevation.
V )Location construction access corridors.

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