20140249 Ver 1_Shoreline Stabilization_20140313

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03/0712014 10:35 2 0 4 0 2 4 9 fa P.0021004
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
-
-- 15A NCAC ON .0500 — Water Quality Certification, Shoreline stabilization
I3Polsion of Water Resources
FORM: SSGP 10 -2073
Shoreline Stabilization Application Form
Four copies of the application (including attachments) and the application fee should be sent to:
Division of water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650
I. Applicant Information [15A NCAC 02H..0502(a) 1
1. Owner Information
Name: ki,&A k%a o Ji
Mailing Address: ?
"Ad yiL
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D
MAR 1 3 2014
Nft - WA ouAL
Telephone Number: q 'Yp— *Z 7--,o-OVT­ Fax Number:
E-mail Address: %'rm'f Ed je!+ A- do 04/tmm . eewl
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
httn: / /www.saw.usace.armv.mil/ Portals /59/ dots /regulatory /regdocs /Permits /SAMPLE AGENT AUTH
OR17ATION FORM.pdf) must he attached If the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: 70Y- d43- Sy77r Fax Number:
E -mail Address: A6 V'4 .- /M KOM/60.00 _f��a •�v_,- �� ___ _
Person to receive the Certification Approval:
I1. Project Information [15A NCAC 02H .0502(a) & ab)J
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
F vegetation -cleating,• structures (buildings, retaining walls, docks, Impervious surfaces,
FARM: SSGP 10 -2413 Page 1 of 4

03/07/2014 105 ffA14 P.0031004
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: 1d,#J&A Nearest Town:
Subdivision name or site:address ,(Include" phase /lot number):
Directions to site - please include, road names,and numbers,,landmar"ks; etc.:
, �l9lrarx 1. � awf. f�.e.I'�l !ad
�Ibo✓yJ td�7i /aka ar .� A t
ctw l ggh `7"A _ -'Z_jwA ^VJ .� 1 Xierr L ti/XP
l0, Ot gEe�o�er�.
5. Describe the existing land use or condition of the site at the,time- ofthis application
(residential, undeveloped, etc:): Y&ACA0441 5)yN h sr l✓
6. Property size =(acres): 044 Axes
7. Lake/ river/ ocean adjacentto property:
8. Descrlbe,proposed work (include discussion as to -how hardenintofishoreline has been
avoided, orWhy it is necessary): °�1�� p,�as jjw &&wi g)az &// gy 1 •�t�_
9. Willwork be conducted from land? From water? ❑
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining, wells, etc.)
below the normal pool lake level / "Normal Water'Level' In square feet or acres:
�� lr9lvr 7;> 4Fr q Sa
11. Total, amount of disturbance (Including allfciearing, back fill,,excavation,.rip' rep, retaining
walls, etc.) =above the normal pool lake level/ formal Water Level and 50 feet land -ward in
square feet or acres: $' -� ><,Low,, V>
12. Please describe the vegetation above the normat pool lake level/ Normal Water Level and
50 feet landward to be-impacted (number of trees, for instance): M6r,
Of- g—"— VA M amass. A 4 7 e,Ws &A/ A r s9 A, .
Owner /Agent's Signature* [15A NCAC 011­1 .0502(fli Date
lAgent's•slgnaturels valid only jf an vuthor1zdtion letter from the owner 1s provided.
,. ,a.: , .. t. .• .. , .�" • ?tat.;;;:_
FORM: SSOP 10 -2013 Page:2 of 3

03/07/2014 1035 M 'P.0041004
` 'Lake
(AtFull Pond / jggT l Watpftgyel)
i• -
l' yw T"• _,
Shoreline
Iz
•fw�. : < %,.,,iy.. .Yo-(:"'!,- '�tv•' %'s''.
B
nod
Please approximately sketch the following Information on this plan (provide dimenslons for each
Item, such as loft x, 00 ft) *:
Z. 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; retainingwalis, docks, etc.
5. Location of any'excavation or dredging below the Full Pond / Normal Water Level elevation
6. Location of construction access corridors
.FORM: SSGP 10 -2013 Page 3 of.3

0310712014 1034 UD PAOT1004
SAMPLE AGENT AUTHORIIAI tON FORM
PROP>:m LEGALDEXR1MON:
LOT NO. Cq PLAN NO. PARCEL. ID: 00 l f 070
yj 9 ' L _ : r
Please pflnt!
Property- Owner: kimay ArA.I. g l-' --
Property Owner.
The undersigned, registered property owners of the above notes property, do, hereby authorize
/p!•Gdla C'061- .,of 9r Af, lea & ble4j e-
(Contractor, / Ag - - (Name of oansultlng'finn)
to act on my behalfand take all actions}necessary for the processing, Issuance and ameptance of
thls;permit or- ceitificaUpmand,any,and all standard. and,speciai,conditiomattached.
Property,Owner's3Address (if difflamd than property above):
Telephone: WO -- $7eo
We hereby certify the above InIlbrmation.submitted In this application Is true and accurate to the
best of our-knowledge.
tlrorized Signature
Dale:
Authorized'.Signature
Labe:

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