20160963 Ver 1_401 Application_20161016

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State of North Carolina
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
Three copies of the applicatio (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit 2 0 1 6 0 9 6 3
1617 Mail Service Center
Raleigh, NC 27699-1617 _._._.-----
a�c��ad�D
I. Applicant Information 115A NCAC 02H .0502(a)]
1. Owner InMe,-J
tion ,/ / OCT 6 2016
Name: M4 •�-1hewS �o �' w c
wG
r RMITTIN
Mailing Address: / a� o _E--- —
Telephone Number: 770 -65d ` 91 76 Fax Number:
E-mail Address: rob, 9'9� /aKoa< C.OA4
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 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: 10 o A /*
Company Affiliation:
Mailing Address: l %-T-D- 10141IJ4f%o1 Pol"i1c,
6ranie Fa I& Al 30
Telephone Number: 7,7,0 -,; Fax Number:
E-mail Address: rob fia t-, e wn, 99 @ V,4he,, . cUrm
Person to receive the Certification Approval: d /i e f lV4 7YA P c.v-5
II. 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 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: Ca(� w e-' Nearest Town: �� �►� { �� �S N• �-
Subdivision name or site address (include phase/lot number): 1 (Q,,i ojicAj JJ1 s( -aa
(015Q fla,, &-iioo p1),u;1t br. "rac {e Fo-Us I./.C. ZR&w Lo* # 6
Directions to site -please include road names and numbers, landmarks, etc.:
ccf��Ilt1-koru Ok1 (-(w4. 33 1, Tw7,J12;k%f d�1f0 �racc (twee_ Th e-0
PtoAila aeck" mt.R.d. PPvt"Arn5"bL, ,,4zHJ w,(I be OAA t., (21.
tULe-cL 4, e0ln 21"Ic iooPo'JL L C)r,'Ikp_�ausejo,IItoe ou 14e
Latitude (in decimal degrees) 35. % T 9 (c0O Longitude (decimal degrees) — g i, 310 �C
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Pe5%d-sk,4,c, I
6. Property size (acres): I. J93 -Lc .
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 70 tN S 'Aa d QtJ2 2 L� f) L/
4kee 66rd,uz 'rrCAA e(•GdtN4, t
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:
No e_-sxav eLli"d,1J4AP"11OCrefg-).Vio, W611(T5ie Lap QLit .rg_ e 3�T XWS -/ IJS44�iGieGl.
11. Total amount of disturbance (including all clearing, backfill, excavation, rip rap, retaining
walls, etc.) above the -normal pql a�level/ Normal Water Level and 50 feet land -ward in
square feet or acres: &_-'XU If- 1iVo cls{� � � or- !Kig ' 0 la"d dr
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): `(kms 14c- 0al d
tle6e_Jc io�o eLNJ Tre-s uik. I uoe- iJ1kP cd• kf4 Lwic 1 %e_ ptcscruc cl
h{t1,- ri'P rap - (,_f`cr �o QkotoyraPfn,
Owner/Agent's Signature* [15A NCAC 02H .0502(f)1
f A�
Da e
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: 5SGP 10-2013 Page 2 of 3

Full Pond/
Normal Water Level
Shorelin®.ee
Lake
(At Full Pond/ Normal Water Level)
R,lo SRP-�ic>aA, f��
NO S" Ike S�Ore�luG uA O -C
-toe l:�k 6j u. 90V riu41G fo
ku,S 4ere,
ro►a
C" o -f'(�e. Shire -s ld ep
(5ee eke Jcc4 sol.!
3'
3`
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
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