20200332 Ver 1_Shoreline Stabilization_20200303

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 - Water Quality Certification, Shoreline Stabilization
FORM: SSGP02-2017 )
WIWA
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent to:
If sending via US Postal Service if sending via delivery service (UPS, FedEx,
etc.)
!Caren Higgins Karen Higgins
DWR — 401 & Buffer Permitting Branch DWR — 401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information [15A i ICAC 02H .0502(a]
1. Owner Information
Name: n( )'1(
Mailing Address:
Telephone Number:
E-mail Address:
2. Agent/ Contact Person Information
Fax Number:
A signed and dated copy of the Agent Authorization letter must be attached if the Agent has
signed this application form. (A form can be downloaded here:
iitfi '/�/lhdL�fW SaV't�s c� a�-~., rni,�o�taisJ�a%c�Gcs/C2�tlidtQl"VJi4��`OCS/P2{I'pltS%SA��FIE AGEPv'T AUTHORIZ
Name: P-, ► 1 i
Company Affiliation:
Mailing Address:
Telephone Number: (q 1GJ 55C13- 7%4ic Fax Number:
E-mail Address:" h Q "iItk1 C s-A-(uc+lci-, nQnncdpCc'ro
B. Project Information [15A NCAC 02H .0502(a) F, (bl]
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 propo::ed locations of
vegetation clearing, buildings, retaining walls, docks, impervious surfaces, 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.
FORM: SSGP 02-2017 Page 1 of 3

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: Fi ax-) C1 Nearest Town: ���kV)V-N
Lake/ river/ ocean adjacent to property: L a h e— Q' '`J CA.,
Property size (acres):
Subdivision name or site address (include phase/lot number):
_ U__'A—
Directions to site - please include road names and numbers, landmarks, etc.: Cncyl -nG A-V)ru at+e
010 Ov an 4 Vra% V , C hu(nIJ t icy%.
C\0LZ3Latitu�de (in eci a g,e �� (� Longitude (decimal degrees) _ 1 � 96(D5
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): LA (%,�C' � � p (' A
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 5+0 �9 'Lr OS i C 0 -kM CObC I Ca 0 A n n f(a
Sa_ e
7. Will work be conducted from.land? &K From water? ❑
8. Total amount of impac s below he normal pool lake level / Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
Temporary impacts in, square feet:
9. Total amount of impacts bove`the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including back (fill, excavation, rip rap, retaining walls, etc.) in square feet:
corridor in square feet: CQ( C��(Y1 �
Temporary impacts (temporary clearing, construction) q
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50
t
feet landward to be impacted (number of trees, for instance): ,I C'.C\ ! � r
11. Signature f
- (0 ®ao
Own r/Agent s SignalDate
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 of 4

12. Please approximately sketch the following information on this plan and provide dimensions!"
each item:
a. All proposed vegetation dearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining waits, docks, etc.
,. i ,...,+;— „f �nx, =Yrnuntinn nr dredLing below the Full Pond/ Normal Water Level elevation
Lake
"At Full Pond/ Normal Water Leven
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Full Pond/ Normal Water Level
w{c LL
Shoreline
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Plan View
Fun POW Normal Wrier U
Shoreline
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Plan View
Lake
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FORM: SSGP 02-2017 Paee 3 of 4

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EXAMPLE AGENT AUTHORIZATION FORM
Prooerty Leeai/V� }1 tul Description:
Parcel ID: Li 5 r
Lot No. (if applicable) Plan No. (if applicable)
Street Address (if applicable)_ 609 Sagamore Drive, Louisburg, NC 27549
Properly owner.
owner Name (print): Marian Lane Bryan
Property owners Address (if different than the above): 110 Stefi Court, Garner NC 27529
owner Signature:
The above registered property owners of the above property, do hereby authorize
? WLP p�� c�-h d of �` i i` s C� �c� l i l y C�hS �LI�'T '► o �
Agent Name Agent Company Name (it applicable)
to act on my behalf and take all actions necessary for the application, processing, issuance and
acceptance of this permit, certification or authorization including all standard and special conditions
attached.
t hereby certify that the above information submitted on this form and application is true and accurate
to the best of my knowledge.
Authorized Agent Name /Company: I�Z) aual�Lj CaoskL=L' op) /Pwi lif pv)w
Authorized Agent Signature:
Date: Off©

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