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Home My WebLink About20150625 Ver 1_Shoreline Stabilization_20150623I- 2p 1 5 62 DWR 5 I- State of North Carolina rt p ment of En iment and Natural Resources 3 2015 Division of water Resources Division of Water Resources DEN& - 0 —Water Quality Certification 401 & BUFF i A plication FORM SSGP 10 -2013 (Shoreline Stabilization 401 WQC to accompany USACE GP30, GP79,_ or 0) Instructions for Shoreline Stabilization Application When to use this form — This application form should be used to apply for a 401 Water Quality Certification to impact: j U.S. Army Corps of Description I Engineers (USACE) Permit Federal Energy Regulatory Commission (FERC) regulated lake ( GP30 shore or bottom 1 Tennessee Valley Authority (TVA) regulated lake shore or bottom GP30 Local government regulated lake shore or bottom GP30 USACE Reservoir owned /regulated lake shore or bottom GP79 Private lake shore or bottom G P80 When this form should not be used — This application form cannot be used for wetland or stream impacts. This information does not apply to landowners within the twenty coastal counties that are affected by Division of Coastal Management (CAMA) rules. For more information — If you have been advised that you require a 401 Water Quality Certification, and would like more information about: ➢ The application process: htto: / /r)ortal.ncdenr.org/ web /wq /swp /ws /401 /certsandpermits ➢ How to download an application form: http://Portal.ncdenr.org/web/wa/swp/ws/401 certsandpermits/applv/forms ➢ Application fees: htto: / /oorta I. ncdenr.oriz/ web /wci/swp /ws /401 /certsandpermits /apply /fees If you are unable to download this information or application, please call (919) 807 -6300 to request an application with instructions. Please note — Not all impacts require written authorization from DWR. This may include the construction of docks or boathouses if there is no dredging or filling involved (other than the pilings). For more information, please visit the following website: http: / /Portal.ncdenr.orp/web /wq/swp /ws /401 /certsandpermits /fags #always have to aDDly How to apply — When submitting an application to DWR, please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these instructions will help facilitate a quicker review time and reduce the amount of requested additional information. INSTRUCTIONS FOR APPLICATION SSGP307980 08 -13 & SUPPORTING DOCUMENTATION Page 1 of 3 Provide four (4) copies of the application and supporting information (maps, drawings, etc.), as well as the appropriate application fee (see below), to the Division of Water Resources, 401 & Buffer Permitting Unit, 1650 Mail Service Center, Raleigh, NC 27699 -1650. Applicant Information ❑ Owner Information: Please provide complete and accurate contact information ❑ Agent Information: Per 15A NCAC 021-1.0502, an agent may be given signatory authority for the owner /applicant if a signed and dated copy of an Agent Authorization letter is included with the application. (A sample form may be found at http: / /www. saw.usace.armv.mil / Portals /59 /docs /regulatory /regdocs /Permits /SAMPLE AGENT AUTHORIZATION FORM.Ddf) II. Project Information v / F-] Vicinity/ Site Map: Some type of site map so that someone unfamiliar with the area can locate your project. A county map or USGS topographic map indicating the project location is usually sufficient. '❑ Site Plan: A site plan showing the location of the shoreline, location of the impacts to the shoreline and /or lake bottom and the location and any vegetated areas that will be impacted. In most cases the site plans do not have to be professionally prepared. However, if you intend to conduct hydraulic dredging, professionally prepared drawings will likely be required for the spoil structures. See example below. ❑ Photograph of shoreline to be impacted/ disturbed ❑ Description of property and existing features on and near the site ❑ Description of project and impacts/ disturbance proposed III. Signature If ❑ Per 15A NCAC 02H .0502 , the application shall be considered a "valid application" only if it bears the signature of a responsible officer of the company, municipal official, partner or owner. This signature certifies that the applicant has title to the property, has been authorized by the owner to apply for certification or is a public entity and has the power of eminent domain. IV. Application Fee ❑ The application must be accompanied by the appropriate application fee (checks made out to the NC Division of Water Resources). The application fee is as follows (pursuant to G.S. 143- 215.3D): v" ➢ $240.00 for impacts to lake (below normal water level) of less than 1 acre ➢ $570.00 for impacts to lake (below normal water level) of greater or equal to 1 acre INSTRUCTIONS FOR APPLICATION SSGP307980 08 -13 & SUPPORTING DOCUMENTATION Page 2 of 3 State of North Carolina DWR Department of Environment and Natural Resources Division of Water Resources Divlslon 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 Raleigh, NC 27699 -1650 Applicant Information j15A NCAC 02H .0502(a)l 1. Owner Information Name: : r, H-P 111jr k5 Mailing Address: Luse" -er LvLI 1 S L'uP) J / Telephone Number: 14--7 5L - tL72I Fax Number: p-- E -mail Address: 1:7e 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.armv. mil / Portals /59 /docs /regulatory /regdocs /Permits /SAMPLE AGENT AUTH ORIZATION FORM.pdf) must be attached if the Agent has signed this application form. Name: _S 1` ;v _e; PC) &I hG Company Affiliation: P11 i L`s Cr u q L: 'T -V eQ r,, Seri, -_h _opt! Mailing Address: P C) >t ) -; Telephone Number: (-7 G, 61?_ Fax Number: E -mail Address: k '� 3 6 -,,� a Person to receive the Certification Approval: 5 t eo � 9 c 1q v,,1 II. Project Information f 15A NCAC 02H .0502ia) & NJ k% 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. ✓�. 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 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 wurk is (o be conducted) County: Nearest Town: A -1,-,1 Subdivision name or site address (include phase /lot number): C ,s , -r-t y � �•�il -P �si� � OG`d Directions to site - please include road names and numbers, landmarks, etc.: Frv,.Y, Zt i\n -�-t! /;cJ 13 ay p t# Lt C h.4 vac k c,,id ILVrA Al 'y h t o Al S,G Pay o Rc"s�T -IA �N�N L� �n� �� C'h�y ��n� �� I�h/ �{, /ht c^ /C/ S I 9e1-2n0,• 9 rE4 e Ai L-eif o1\1 7�`d r � r s �°�'I�o LL A/ 5. Describe the existing land use or condition of the site at the time of this application (resi=dential, undeveloped, etc.): /= K t S5p Q rl 6. Property size (acres): c �3 7. Lake/ river/ ocean adjacent to property: L_d /C--, Ao E a /-.,, 8. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or why it is necessary): F) �- rtys�'c' � !�� C_w�tV 1pr._� LA ViQNv`a�,l Ll.i� �OLi��Li ) 9. Will work beAnducted from land? []` From W/�ater? ❑ 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: i2 CI_5f 4d "i�xca6L i,9Z t;'0AI i N Wdi N,1 i sl J �L 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): h rr., es 'n-r�� Owner /Agent's Signature* (15A NCAC 02H .0502(f)1 Date 'Agent's signature is valid only if an authorization letter from the owner is provided. FORM: SSGP 10 -2013 Page 2 of 3 -4 c4ia Lake (At Full Pored /(Normal Water Level) Full Pond / V. T ULTA Normal Watert evel 3i Shoreline i►5 ,e, °'�k �� , 17 w rL uL K k JA 6 Y v Y E . 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 Fir- TP IV a T'�` zk -15 rC Ff hu ) Y' ,P 61 te Seroo Vt- _ . c . • J1.," iv i EXAMPLE AGENT AUTHORIZATION FORM Prooertv Legal Description: Parcel ID: Lot No. (if applicable) _ _ _ Plan No. (if applicable) Street Address (if 3 applicable):_ J t _ f () Sf;� r (q v .f'. Propertv Owner: Owner Name (print): ige , < <r U.4 4 Property Owner's Address (if different than the above): id Owner Signature:- _ The above registered property owners of the above property, do hereby authorize 14) oGu h of j h 5 u f Agent Name Agent Company Name (if applicable) to act on my behalf and take all actions necessary for the application, processing, issuance and acceptance of this permit, certification or authorization including all standard and special conditions attached. I hereby certify that the above information submitted on this form and application is true and accurate to the best of my knowledge. Authorized Agent Name / Company: Authorized Agent Signature: 3 Date: r!-!.7 40n 1 r •.ryy� T * y� t�� .. • fir.. '` jA rte' 1. "�'?';, !'•y.,•�(�. AIP u t y . I Pf Mir, r a- IA OIL Of - x 4 •r jr c Ila i 1. .7-7 KA ' 733^7X " •r jr c Ila i 1. .7-7 KA