20141300 Ver 1_Shoreline Stabilization Application_20141218

2 0 1 4 1 3 0 0 State of North Carolina
Department of Environment and Natural Resources
DWR 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
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
I. Applicant Information [15A NCAC 02H .0502(x)]
DL9C@I�vlr
1. Owner Information 1
DEC: 1 �� 2014 _;
Name: RITCHIE SOOS
Mailing Address: 4218 Patriots Way - ? J.
8_ g��R i�ERH?7af�iG
Gastonia NC 28056
Telephone Number: 704 - 277 -5658 Fax Number: 704 - 816 -5469
E -mail Address: ritchie soos @premierinc.com
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.arM_y. Portals 5.9 /docs/ regulatory /regdocs/Permits /SAMPLE AGENT AUT
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: Robin Lemons, Owner/ General Contractor
Company Affiliation: Summit Construction, LLC
Mailing Address: P.O. Box 353
Albemarle, NC 28002
Telephone Number: 910 - 220 -2806 Fax Number: 910 - 439 -4765
E -mail Address: summitconstructionllc @gmail.com
Person to receive the Certification Approval: Robin Lemons
II. Project Information [15A NCAC 02H .0502(aL &Ab.]
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 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 conducted)
County: Montgomery Nearest Town: Mt. Gilead
Subdivision name or site address (include phase /lot number): Swift Island Plantation,
Lot #33 314 Plantation Way
Directions to site - please include road names and numbers, landmarks, etc.: Hwy 24/27 to
Hwy 73. Turn onto Lilly's Bridge Rd. Turn right onto Plantation Way. Construction
entrance gate code is #4488.
Latitude (in decimal degrees) 35.277908 Longitude (decimal degrees) - 80.083776
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Residential
6. Property size (acres): 0.82 acre / home site size
7. Lake/ river/ ocean adjacent to property: Lake Tillery
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Dredging of navigable waters, construction of pile -
suonorted pier. Shoreline stabilization with natural boulders.
9. Will work be conducted from land? X❑ 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:
1.650 so. ft.
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: 1,800 sq. ft.
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): Approximately ten (10)
/Z ps-// V
Owner /Agent's Signature* [15A NCAC 02H .0502(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

IlP-
Full Pond/
Normal Water Level
i i i ■
Shoreline
l 5'x�ao
La ke
(At Full Pond /Normal Water Level)
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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
?. 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.
S. 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

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Legend

Soos Residence
Morrow Mountain SW Quad Map
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