20220343 Ver 1_Shoreline Stabilization_20220307

State of North Carolina
DWR Department of Environment and Natural Resources
Division of Water Resources
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 att and the application fee should be sent
d Idadd119 lOt,
to: giownosad ti3LVM-ma
Division of Water Resources \\�`
401 & Buffer Permitting Unit ZZQZ L _ Iv ,l` ri
1617 Mail Service Center Vv
Raleigh, NC 27699-1617 C'o J jt A'
a3A13O3H
c
Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: 0, s IAA5ter/ iZ' c‘R (�')
Mailing Address: c( SA- V1l t))LI_s %Zt,<<
1t} ' -f � �✓ 1/C 7a‘2P'/
Telephone Number: 9L("Plq �S'�.3 Fax Number:
E-mail Address: i11 v40 q$ r V C4, ,%J � rnq / d c cw)
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/docs/regulatory/regdocs/Permits/
SAMPLE AGENT AUTHORIZATION FORM.pdf) must be attached if the Agent has signed this
application form.
Name: cvvlrvi V ea,/
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Person to receive the Certification Approval:
e61-i Kai �vl
II. Project Information [15A NCAC 02H .0502(a) & (b)] / uc s
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 urfaces
FORM:SSGP 10-2013 Page 1 of 3

As V rt E,$) /12 if2c,A- Pi fr
S79.. E 14 E kcif
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 J conducted)T
County: /9T1 K5 n/ Nearest Town: / �c (c
Subdivision name or site S address (include phase/lot number): 7a-, i -w-
al- n
11K! I?OAO , )tc1c-Pr s LAG K ✓i2_ ac3'?�j�'
Directions to site - please include road names and numbers, landmarks, etc.:
PP) oaci- 511(4 (9°st (nJL(-ehiv,vrr c.
/-y Ev C /m✓4-OR p8iS
91,,.1 1,7 &Al f „44.4,.41 -/�
t ot± �-a whz I' C�aw�►., q(rcc v L3 PwV� P go r
Latitude (in decimal degrees) 35-11-/ Longitude (decimal degrees) 83, 3
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): �(�s (0// CC, M I-r, Avi L,&Al
6. Property size (acres): c'3 4 }
7. Lake/ river/ ocean adjacent to property: isK E wnCA\
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): S N o, E )-11u c 15 c tyP 1 h y fin O
�U D I N c) co r n "i'-ee IA/To r'i(/A--re
9. Will work be conducted from land? ge_s 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 landward to be impacted (number of trees, for instance): •-----71065 } E
A g0I/ c IA pp 1 vlo P-1 s�aye H �Q 'N// U/ i 1I h�
5 -v -j cuw\ f r3 ccryv y 1 h ,
OA" id.4e4t 02, L ai#01
Owner/Agent's Signature* [15A NCAC 02H .e2ffil Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM:SSGP 10-2013 Page 2 of 3

Lake
(At Full Pond/Normal Water Level)
w ( dui cicN 6 4
g a40
Full Pond/ /8 -ft y,, 9 W
Norma--- - NMMIMIN INIIN �
Shoreline
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 Level elevation
6. Location of construction access corridors
r V o eCi . r--ePaY 114
6' AAc.riP
FORM:SSGP 10-2013 Page 3 of 3

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