20140827 Ver 1_Shoreline Stabilization_20140804

State of North Carolina
DWR Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources
FORM: SSGP 10 -2013
Shoreline Stabilization Application Form " 0 1 4 0 8? 7
Three copies of the application (including attachments) and the application fee should be sent
to:
1
FEI
Division of Water Resources
401 & Buffer Permitting Unit �' %�
1617 Mail Service Center
Raleigh, NC 27699 -1617
Applicant Information [15A NCAC 02H .0502(a)]
Owner Information„ , �•.
Name:
Mailing
•r
Telephone Number: %^ 575 ��lo //W Fax Numb r: 7V/--,2J0--z:5,5 /
E -mail Address: �/i7 VV�?��r' C`z • D/1�
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 mii /Portals /59 /docs /regulatory /regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: ,, / ZA
Company Affiliation:
Mailing Address:
Telephone Number:
E -mail Address:
Person to receive the Certification Approval:
Fax Number:
4 2014
Il. 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 play showing property boundaries and proposed locations of
vegetation clearing, structures (buildings, retaining walls, docks, impervious surfaces,
FORM: SSGP 10 -2013 Page 1 of 4

t
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 ofltroperty (where work is to be conducted)
County_. �� �Y Nearest Town:
Subdivision name or site address (include phase /lot number)- 7TA0
Directions to site - please include road in mes and nu i'bgrs, landmarks, etc.: A, "AMJ;'; �K"
Q /[� D
L1117 1� U'y "— v c � 'V
/ 07 /
Latitude (in decimal degreesi r If ���Pl ongitude (decimal degrees) —f •130 p 40/ 1
5. Describe the existing land use or con on of the site at t time of 's application
(residential, undeveloped, etc.):
6. Property size (acres): �C1S
7. Lake/ river/ ocean adjacent to property: /G L�
8. Describe proposed work (include discussion-as to ho )- ardening of shoreli a airs been
avoided, or why it is neeessary): L//✓� Apes
o
9. Will wor be conducted from land? ❑ From wate 'r?
10 Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool, I- ke level/ Normal Water Level in square feet or acres:
6 ( / .� �.
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/ No_A,fI Wader Level and
50 fie x landwa d to be im cted (number of trees, for instant :
/l am � $ i✓� . 1.- _"Ada r //✓ �
Alll_�Iaec /
- - _: � A� IJ4, - 0 ZAZ zl"L/ - A, /' t 5" �� - X-© / -/ -
wner /Agent'sSign ure' [15A NCAC 02H .O5O2(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

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Latitude and Longitude of Point
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Decimal Deg. Latitude: �
Latitude: 135.174261
Decimal Deg. Longitude: IF
Longitude: -83.13&114
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Latitude: jii-- 110 27.3396
Latitude: F +— I
Longitude: -83 i8 18.2898
Longitude:
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