20110870 Ver 2_401 Application_20161016

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^� State of North Carolina
Department of Environment and Natural Resources
\n 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 application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center D
Raleigh, NC 27699-1617
2016
I. Applicant Information 115A NCAC 02H .0502(a)j 4�1 BR R
1. Owner Information �. FFER pERA�I�NG
Name: 1_467Y? S. t-Ox
Mailing Address: I Z.'3 0 5• OIrNI4,0- 4 "'e
5400 Sv"`A, mac- 3kf2 311
Telephone Number: y4//-ZCvb - 9Z-061 Fax Number:
E-mail Address: �.�>< /� oc 4P.6e7w1
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. df) must be attached if the Agent has signed this application form.
Name: 6g A)
Company Affiliation: zxy "-GG CD, ,L3ow!pS
Mailing Address: 8 - 130 3a
61G4k:Nyl44146 X%C. Z*734
Telephone Number: z9�Z' *-226 Z0(/7 Fax Number: -7(I.3-6 2 6
E-mail Address: o py oa SG @ C;L o /. co--s
Person to receive the Certification Approval: /36 7. /,V4 -774S
II. Project Information 115A NCAC 02H .0502(a) & (b)) 70
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: Nearest Town: [ U VILLA
Subdivision name or site address (include
phase/lot nu `
number): / +C)06-1
,� .,
S77-a-c- /9d/ly % 46 ' 6 � 7 ( 2,C) 7 ' ) c� ci)M6)wlrZ
Directions to site- please include road names and numbers, landmarks, etc.:
tQ�m Q 7 y'1 L(,E ;y2A.) olo y1u_'0_r- suoal_Rb
To 4AAC 9 s/i0)S� CCa CL E 0 A/-A""T T S7r?c�/�aiNi
642-K v,1J Z-6,02_ Ta 3 Zz->
Latitude(in decimal degrees) rI73r28 Longitude(decimal degrees)—&T,
5. Describe the existing land use or condition of the site Atte time of this appl' ation
Lv �c5T7
(residential, undeveloped, etc.): ®�?rs Ste- ,X � Z4°Pry 40 1
6. Property size (acres): _ -2-,,o D 4,A eb,111,6IA✓A!D1
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): A�*Y;Z ,��CISr N�=- l✓"' Gc>.�-� o
,4-r- wr
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:
7S-0
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: 7Sfy
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): d-o'`/�-
Owner/A is gnatre* 115A NCAC 02H .0502(f)1 Date
Agent's signat is valid only if an authorization letter from the owner is provided.
FORM:SSGP 10-2013 Page 2 of 3

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