20141059 Ver 1_Shoreline Stabilization_20141006

DWR
Division of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10 -2013
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 �F • ' ' r
4�
Raleigh, NC 27699 -1650 �
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information ./
Name: 1-.1110A �/�J b /V -./ f}1Ti4/`Z
Mailing Address: / x g e' 31- r'6RR -f e't
Telephone Number: 9111- 1"20 -;r'5v/ Fax Number:
E -mail Address:
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
htto : / /www.saw.usace.arrnv.rnii/ Portals /59 /dots /re�,ulatoiv /rep,docs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: X110
Company Affiliation: /%? ' %�^► ��i /_�D�S IyWe S SF *uJ44 L C i
Mailing Address: /? U . /30X ?o q
2 & 726-
Telephone Number: ` ,?e-ZZG - L&y7 Fax Number: 82P- ZV2 4,260
E -mail Address: Jn..wr�,6 0, S—� Cp (.LC %. C c.-N
Person to receive the Certification Approval:
H. 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 locations of
vegetation clearing, structures (buildings, retaining walls, docks, impervious surfaces,
FORM: SSGP 10 -2013 Page 1 of 4

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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: ��.�Oti� Nearest Town:x�<<
Subdivision name or site address (include phase /lot number)-
Directions to site - please include road names and numbers, landmarks, etc.: ' �e,6,y!
z�� Lce 'Albe;?l o "1 "'07 7b i aew AFT 60 Tv
`,wi,r - '4i x2 s / %iii ! i yi2i✓ 21,e4-177 6� .D i 0 16z Z) c)- j�.v c' AliY
j,& ACK& Ali le&.Ao. Lv146 €A?rAE &IZZ v.J
l�f�r
5 Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc): 1161V9 X17%_
6. Property size (acres): % 0 f
7 Lake/ river/ ocean adjacent to property: I*Arg:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why It Is necessary). 7b C'Z►� -�S �C�" .¢ sf%�2 c.ia� S'T✓h4�LI24n0-'►
9 Will work be conducted from land? ❑ From water? RX
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:
/0 37, S(A
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. 103-7,5- .S Q FA-F
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): 'o ocofjfif b 7VJg_k5 64
%a ,6� /�l�:r� .rtr✓_o �!9 /�u�c�9-c. �t,'��c-� i`v B >r � /S?uf�£�O a'z.�. i�'''�/'?c:i
Own /Ager�'s-�ignature* (15A NCAC 02H 0502(f))
2-7,0 - Z,014--
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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