20141005 Ver 1_Shoreline Stabilization_20140922

201 41 005
State of North Carolina
Department of Environment and Natyr hesources
DWR
Division of WateResources
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
Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: M A H (J&*_&L 4 J)o 2.; S M i c.
Mailing Address 3 3 Cti. l ho Iry
A 1 Emkit ld k .C. •
Telephone Number:
E -mail Address:
ProP�'y r'-14 -a is.,
2 y g Seri wood `Dr
rvt�= Crt'le
t I AT
7 2014
701 j8 )_ ? g3•5�Fax Number: �� ' 41 N I—EI '
�— �r�F, ,"F
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 /dots /regulatory /regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation: LA AICE 5 3 dJ-t5 • G' o N lik"CAOR —s
Mailing Address: I t? 5 2 f L r 72-edy
IV aA &j a, o o/ rig • 4 2 / 2 �
Telephone Number: ?6V• 1132? 0 to Ito Fax Number:
E -mail Address: 'Fa =+l f q V 9 ir%f N64 SkQe-4 &I , Al 4C
Person to receive the Certification Approval: o btv--4• 94 ] ! P,5 keg-
11. 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 location jbf
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 conducteed_)1 _
County: Nearest Town: Na-
Subdivision name or site address (include phase /lot number): 26k
Directions to site - please include road names and numbers, landmarks, etc.:
'r'o Iry 7 L-,r
r
Latitude (in decimal degrees) 35, 01 7 No Longitude (decimal degrees) ��. ?` Q _ 7
5 Describe the existing land use or condition ,of the site at the time of this application
(residential, undeveloped, etc.): Jqe-s i Ate
6. Property size (acres): A $? aG,
7. Lake/ river/ ocean adjacent to property:
8 Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): QC4.Koje i J a 8p i J.&J-i'4 L r&,&
i
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:
3 X LJVO nZc f. y 'Pi'
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: 3 16 L06 ,r+ 12d 6 .72
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):.SeVb1Rd61
Owner /Agent's Signature*
4044 "11A,
Printed Name
[15A NCAC 02H 0502(f)l
`Agent's signature is valid only if an authorization letter from the owner is provided
FORM SSGP 10 -2013
lilt
pate
Page 2 of 3

Full Pond/
Lake
(At Full Pond/ Normal Water Level)
to
l� p
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
FORM. SSGP 10 -2013 Page 3 of 3

1,
North Carolina,Department of,Cultural Resources
State Historic Preservation � Office
Ramona li Battos, Admrrustrator
Govemor Pat'McCrory
Secretary Susan'kluttz
July 10, 2014
Robert Gallagher
Boat Houses on Tillery
10579 Willow Oak Road
Norwood, NC 28128
Office of Archives and,History
Deputy Secretary Kevin�Chetry
Re Maynard and Dons Stickney, Soil Disturbance, 298 Springwood Drive, Mount Gilead, Lake Tillery,
Montgomery County, ER 14 -1522
Dear Mr Gallagher-
Thank you for your email of July 5, 2014, concerning the -above project
We have conducted a review of the project and are aware of no historic resources which would be affected by
the project Therefore, we have no comment on the project as proposed
The above comments are made pursuant to Section 106 of the National Historic Preservation Act and the
Advisory Council on Historic Preservation's Regulations for Compliance with Section 106 codified at 36 CFR
Part 800.
"Thank you for your cooperation and consideration If you have questions concerning the above comment,
contact Renee Gledhill 'Earley, environmental review coordinator, at 919- 807 -6579 or renee gledh&
earley@ncdcr gov In all future communication concerning this project, please cite the above referenced
tracking number
Sincerely,
�L -6
Ramona M Bartos
L)
Location 109 East Jones Street; Raleigh,NC 27601 Mailing Address 4617 Mad Service Center, Raleigh NC 27699 -4617 Telephone /Fax ,(919) 807 - 6570/807 -6599

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SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT N0. PLAN NO. PARCEL ID
� 6 7yl2 9S3101
STREET ADDRESS: � GI � -S -�n�- '�'
Please print:
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
V ]—a 'q. 00J'- /' a,,,, , , 1<2'
of
(Contr ct / Agent) (Name of consulting firm
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above),
Telephone:
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature
Authorized Signature
Date: Date: