20160891 Ver 1_Shoreline Stabilization_20160913

State of North Carolina
2 0 1 6 0 S 9 Department of Environment and Natural Resources
DWR Division of Water 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
1617 Mail Service Center
Raleigh, NC 27699-1617
1. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: A / AV- Appc.-sa�/
Mailing Address: 343 /
5LE
SGpn ol` ' /ve- d2 73 Y_?
Telephone Number: all �Fax Number:
E-mail Address: Wet Son Q M411
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.army.miI/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: lbky/D P'041n"r— Peq/n�.c✓L Sc lrlT
Company Affiliation: bu_rm I ---
Mailing Address: K. o -"e- 6
%lm JXr1 We_,r ivy
Telephone Number:J'/ -770-580 Fax Number:
E-mail Address: O4fn e 2teZ.�__ fid• �d
Person to receive the Certification Approval:
11. 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

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 tf e property (where work is to be conducted)
County: 6� 0 /V,- Nearest Town: 561? D/ -4 -
Subdivision name or site address (include phase/lot number):
35l' &0!7 cal -pt -e- ILL 273Y3
Directions to site - please include road names and numbers, landmarks, etc.:
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:j�C
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it its necessary): 44& 17,tS Atlee—,,
9. Will work be conducted from land? t 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:
loo 0 -r -r-
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: ">L ? r/
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):
16 /`c� 7'SP4// f �j 91-663 �*-.mit- %�w� /4"— AD' Pk �CG/I.�'
-rp
o,
Owner/Agent's Signature*er
-Agent's signature is valid only
APAP
Date
letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

R
Normi
S
Lake
(At Full Pond/ Normal Water Level)
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.
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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