20160061 Ver 1_Shoreline Stabilization_20161119

F_-)
f 20160061
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee
should be sent to:rf—
Division of Water Resources Iln! `_
401 &Buffer Permitting Unit u`rikIV 1 9 2016
1617 Mail Service Center
Raleigh, NC 27699-1617 ,DEQ-WA1E— P RESpURC
• Applicant Information [15A NCAC 02H .0502(a)l
1. Owner Information
Name:
Mailing Address: //5S-3 1WPQJAnn W -1L -
,E30 97
Telephone Number: _���_- 517_- /3(5 Fax Number:
E-mail Address: In4homt-OLS4 ra- roc.Ly.-PPil M
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.a rmy.mi I/Portals/59/docs/regulatory/regdocs/Permits/SAM P L
E AGENT AUTHORIZATION FORM odf) must be attached if the Agent has signed
this application form.
Name: �2..04 W.Sorn
Company Affiliation:
Mailing Address: S'fsot F e, Fa i?_j .
QIDVVr, s -c. 2 g-7 I'D
1

Telephone Number: Fax Number:yo3- 63i- SUSS
E-mail Address: rc'Cay.153.5 P PaOkl;Alc r^a
Person to receive the Certification Approval:
• 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.
• Provide a detailed site plan showing property boundaries and proposed
locations of vegetation clearing, structures (buildings, retaining walls,
docks, impervious surfaces, 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.)
• Location of the property (where work is to be conducted)
County: &us�on Nearest Town: -i�eln&onA-
Subdivision name or site address (include phase/lot number): k
MGL ZroQar+., sul,a;v�.ov%
Directions to site - please include road names and numbers, landmarks, etc.:
.P_5.s ,b )
_ f _ I_ . .LL _ . .L.. _ Ll _ 1,_ /'_ _ it r O./_ _
Latitude (in decimaidegrees) 9S 09' l . SSS' sM Longitude (deamaidegrees) Si
GZ' 03.52" UI
• Describe the existing land use or condition of the site at the time of this
application (residential, undeveloped, etc.): _ IAnr. t4 r_1,pQc )o+
Property size (acres): . % % ci c r -e S
9 Lake/ river/ ocean adjacent to property: Wv lie-

Describe proposed work (include discussion as to how hardening of shoreline
has been avoided, or why it is necessary): Cfea� e. � roh. 155' o
/ 11 a1/0 Hr a. 1 s ' b 4e_(- ms �e Il .
7 d' PIMC.Q. opgcax / i-/ SSS 010CICISS _1� r"f
Will work be conducted fro an . From water?
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: 3gW 4. �4. /2 % , H e /S 419�
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: /G 6' s4 ff
�z,k/s �se- -?- 8'X/5S,acc53 roaA
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): Moldy unc&-brita,. (V,6 rs") . I (16" & 7o")
Uasidx- e4' A -MRS +KAL are_ umdjA LK"+v12") (n/e W;(( ka✓t
all -fres rvssw5 . '411 d, s-tC.-cy{karcLs -/�p b.- s4tA�r 4�e:1
g,"ap? 00, �,�7
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.

Lake
(At Full Pond/ Normal Water Level)
SSS
.y
Rd
e L✓ fNlal
t' if fo f f
Full Pond/ ,
Normal Water Level \ /,
an ®®�
Shoreline
lp a�
r�
13,X55
suazaota-
gI SSS 'Access Rda�
Please approximately sketch the following information on this plan (provide
dimensions for each item, such as 10 ft x 100 ft)*:
• All proposed vegetation clearing
• Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level
elevation
• Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level
elevation
• Location of any proposed structures such as buildings, retaining walls, docks, etc.
• Location of any excavation or dredging below the Full Pond/ Normal Water Level
elevation
III
I��
/A�7° 1
2Chnll) �0
.. _n_ ass -,.p. e.-1ili::c;Ct Pa;:nPcnt
-���
Hame Nsut
Hesipn Num:Loni � Sftl Slaw. . _Rolm T L35esnN<
gide-otleee
.fl r y - _ I i _ .. is •�: .-... ...
:l%1{ }
:eCbag(1 %
Inas '.
Fah ., .'ats^.rsort
Lake
(At Full Pond/ Normal Water Level)
SSS
.y
Rd
e L✓ fNlal
t' if fo f f
Full Pond/ ,
Normal Water Level \ /,
an ®®�
Shoreline
lp a�
r�
13,X55
suazaota-
gI SSS 'Access Rda�
Please approximately sketch the following information on this plan (provide
dimensions for each item, such as 10 ft x 100 ft)*:
• All proposed vegetation clearing
• Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level
elevation
• Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level
elevation
• Location of any proposed structures such as buildings, retaining walls, docks, etc.
• Location of any excavation or dredging below the Full Pond/ Normal Water Level
elevation
III
I��
/A�7° 1
2Chnll) �0

• Location of construction access corridors

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 3 2 PLAN NO. PARCEL ID:
STREET ADDRESS: -343 L" 0,5.14 �z
�1jr_lwtoir,�-i JV.C. ZR"012
''Tlease;print-
Propbht -.Owne
The undersigned, registered property owners of the above noted property, do hereby authorize
(Contractor / 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 9 ;" ADG hodzed5ignature
Date ��G - Date: ' / % "

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