20191686 Ver 1_Shoreline Stabilization_20191210

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
D R
W,
15A NCAC 02H .0500 - Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
1
Division of Water Resources
401 & Buffer Permitting Unit
1627 Mail Service Center
Raleigh, NC 27699-1617
Applicant Information [15A NCAC 02H .0502(a)]
Owner I
Name:
Mailing
DEC 10 2019
Wwor wurces
Telephone Number: ' C J��� " ISO Fax Number: � � � - q�
E-mail Address: G r� Lr e_
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http://www saw usace army mil/Portals/59/dots/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Person to receive the Certification Approval:
II. Project Information [15A NCAC 02H .0502(a) & (b)]
1. Attach a vicinity map (i.e. street map) clearly showing the location of the property with
respect to local landmarks such as towns, rivers, and roads.
2. Provide a detailed site plan showing property boundaries and proposed locations of
vegetation clearing, structures (buildings, retaining walls, docks, impervious surfaces,
FORM: SSGP 10-2013 Page 1 of 3

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etc.), rip rap, excavation or dredging below Full Pond/ Normal Water Level elevations,
and construction access corridors. You may use the diagram provided at the end of this
application form.
3. Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale
of some sort- a yard stick, shovel handle, etc.)
4. Location oftheproperty (where work is to be conducted) ``
County: �J '(.lC�S © n Nearest Town: ` i✓n V I ( te..
Subdivision name or site address (include phase/lot number):
,�, as r7 FP_ n lei[ Fores-4 Tr I
Directions to site - please include road names and numbers, landmarks, etc.:
Ii c
Latitude (in decimal degrees) 5• I �� Ongitude (decimal degrees) — 0 3 g tea• b.� �' �
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): 02S4CACrrh cd
6. Property size (acres): s .�i ACY'e5
7. Lake/ river/ ocean adjacent to property: (--�k5e C 4e�nv ll
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): re-D Q 1 r Q.�C( S-H h4 W a--( I
9. Will work be conducted from land? []� From water? ❑
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake level/ Normal Water Level in square feet or acres:
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres:
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet 0.Y llandward to be impacted (number of trees, for instance):�63jhmc\im
Q i' 2 aeA we —cc �-' ��CUVC lr` / [,t siz s
(�—D 1� (, C L-11-6
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Owner/Agent's Signature* [15A NCAC 02H .0502(f)] Date
`Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

La ke
(At Full Pond/Normal Water Level)
L
Full Pond/
0
Normal Water Level 1
SI
Dom.
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Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft)*:
1. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation PJVII
3. Location of rip rap or fill to be placed below t e Full Pond/ Normal Water Level elevation r
4. Location of any proposed structures s�'as bui s, retaining walls, dg<etcct-��tjl �onc
�6$'1e, Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corridors may- \Dr o v6rty
FORM: SSGP 10-2013 Page 3 of 3

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