20150914 Ver 1_Shoreline Stabilization_20150904

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC QZH_ 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
2
1617 Mail Service Center , 5 9 1 4
Raleigh, NC 27699 -1617
1. Applicant information j ]
1. owner information 1
Name: D�e-rT /��r�
Mailing Address: 94 %/ �i,
u SEP ® 4 2015 1.0
40.1.&' BUFFER Pii rvljl tf
Telephone Number: %%�3"� �9Fax Number:
E -mail Address: rfa -%// _ ,
2. Agent/ Contact Person In matton
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E -mail Address:
Person to receive the Certification Approval:
11. Project Information [ ]
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.
✓1. 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

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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.
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: /ry 'I /i✓ Nearest Town:
Subdivision name or site address (include phase /lot number):
Directions to site - please include road names and numbers, landmarks, etc.:
f Do✓ _ Zu rct / a� �. Dnl o . 9'c1AOM
�- 3 ry I C6 ,v- od River b y x
Latitude (in decimal degrees)
Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): -J dery /i -ea,
6. Property size (acres): A 2I' acrd's
7. Lake/ river/ ocean adjacent to property: z2'k e—, �r?e V—tw_a nt
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): /l i o '� da_lA r of 2t4 -
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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:
NDit/tf�.
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: _42,0y),rli Y. l D !0'i&20 C /I *dnf
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):
I nor,' �.� /� a fit- $ "�QX _ 7S "tees le f't
��ANcJ �✓�
owner /Agent's Signature* [ 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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Full Pond/
Normal Water Level
Shoreline
Lake
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Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 1Oft x 100ft) *:
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. How'e"
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation None
6. Iocation of construction access corridors
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FORM: SSGP 10 -2013 Page 3 of 3

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Borrower /Client Robert Wilson
Property Address 8671 Graham Road
City Denver
Lender
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Plat Map
County Lincoln
State NC Zip Code 28037
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Borrower /Client Robert Wilson
Property Address 8671 Graham Road
CO Denver
Lender
Plat Map
County Lincoln
State NC
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Zip Code 28037
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