20200288 Ver 1_Shoreline Stabilization_20200220

State of North Carolina
Department of Environment and Natural Resources
DW Division of Water Resources
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Division of Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
I. Applicant Information [15A NCAC 02H .0502(a
1. Owner Information
Name: _ ) otZO A LAM> ONs
Mailing Address:
-71
Telephone Number: 980-M-N-I i Fax Number: 1 N
E-mail Address: IACION_. .o(�4P�.( yly�oo. C�+yt
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/PortaIS/59/docs/regulatorV/reRdocs/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: `704-(o0a-2.( 19 Fax Number:
E-mail Address: 1A.rtoa_ \oa.oa 4
Person to receive the Certification Approval: Jlc4op.J LA►R.fc.Sf
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

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 of the property (where work is to be conducted)
County: (Aowl6t*ME'iLNearest Town: Trod
Subdivision name or site address (include phase/lot number):
a i G 1 e- O n1 �ic-, I e%t� 1 r L o+ *� to
Directions to site - please include road names and numbers, landmarks, etc.:
&t, t3 10 2q%2-7i i-urJ (4:K -M oi'l (ZsV . tom,_ a�2 v,,W
Latitude (in decimal degrees) 35 . 39945 Longitude (decimal degrees) M) • 0109 L I
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Mai 1,04- 1,5 L3.1.,WxAami
6. Property size (acres): O • S b1cc`t.-S
7. Lake/ river/ ocean adjacent to property: /_eKe_
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 13ew .�2c- Sk.mWie
An
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:
Zs oo - 3 000 sco.. CA-
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: —7S—T)D — BScD
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to be impacted (number of trees, for instance): 9 eN'+1!!
p� c -4t ae-S sue- z1�r s
Owne Agent's Signat 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

Full Pond/
NormaLevel
Shoreline
v`
C �
La ke f-. I loj
(At Full Pond/ Normal Water Level)
l.v�sac_s�wnal,�,,a _
6,1"0 V )-e •f f � -
9 a*t%+-Yfjr,
scr-,k*- Qt,ac teas
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
3. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
4. Location of any proposed structures such as buildings, retaining walls, docks, etc. _ _
5. Location of any excavation or dredging below the Full Pond/ Normal Water Lev elevation
6. Location of construction access corridors
e-
l�( (. c
L(4kQ—
r
FORM: SSGP 10-2013 1 Page 3 of 3

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151' of
y Shoreline
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