20171394 Ver 1_Shoreline Stabilization_20171030

Division of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
copies of the application (including attachments) and the application fee should be sent to:
Division of Water Resources
401 & Buffer Permitting Unit
1k4W Mail Service Center T 3 9 4
Raleigh, NC 27699-1650
U C T 3 0 2017,
I. Applicant Information [15A NCAC 02H .0502(a)j
1. Owner Informati n DA _R RESOD S
1 UFF R P
Name: M\\�-�` �'r
Mailing Address:
Telephone Number:`3 �-���\l,o Fax Number:
E-mail Address:
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:
Company Affiliation�_ \N
Mailing Address:
Telephone Number:`�L�`��3\ \�3 Fax Number:
E-mail Address: ��rc��G��he'c1t�'�=`c"S�C1����� �p
Person to receive the Certification Approval:�M
II. Project Information [15A NCAC 02H .0502(a) & (b)j
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 the property (where work is to be conducted)
County: I -SN Nearest Town: C -Xww.-�gAe_
Subdivision` rMe or site address (include phase/lot number): V$ �\�e. rc p�-•�
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.): \1xNaeY e_\pde-
6. Property size (acres):
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): Sl&c -I-a.
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:
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normalater Level and 50 feet land -ward in
square feet or acres: \%°1 I.!S __cll_�Nj zs�4r
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): C -3L ©t
Agent's Signature* [15A NCAC O2H .O5O2(f)]
Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

FI
Norm
S
La ke
(At Full Pond/ Normal Water Level)
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10ftx 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.
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

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. !S20s, PLAN NO. PARCEL ID:
STREET ADDRESS:
Please print:
Property Owner:
Properly Owner.
The undersigned, registered property owners of the above noted properly, do hereby authorize
\ern o0 mom. , of
(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):
iVCc
Teleptwne: ��'�� - \V�lIL
We hereby certify the above information submitted in this application is true and accurate to the
best of our howledge.
Authorbed Signature Authorized Signature
Date: ©\c�lj�\""l Date:

*1/25/2V17 5850 Charlotte Hwy, Clover, SC to 12962 Waterthrush PI, Charlotte, NC 28278 - Google Maps
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Waterthrush PI, Charlotte, NC 28278
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5850 Charlotte Hwy
Clover, SC 29710
Take SC -49 N and Shopton Rd W to Island Point Rd in 3, Steele Creek
115 min (10.3 mi)
t 1. Head northeast on SC -274 N/SC-49 N toward Catamount Dr
1.8 mi
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3.0 mi
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3.1 mi
Continue on Island Point Rd. Drive to Waterthrush PI
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47 5. Tum left onto Island Point Rd
1.0 mi
r+ 6. Tum right onto Fox Sparrow Ln
407 ft
,01 7. Turn left onto Sweetleaf PI
0.1 mi
https://www.google.com/maps/dir/5850+Charlotte+Hwy,+Clover,+SC/12962+Waterthrush+Pl,+Charlotte,+NC+28278/@35.117072,-81.0679711,14z1am... 1/2

1A/25/2017 5850 Charlotte Hwy, Clover, SC to 12962 Waterthrush PI, Charlotte, NC 28278 - Google Maps
r► 8. Tum right onto Waterthrush PI
0 Destination will be on the left
0.1 mi
12962 Waterthrush PI
Charlotte, NC 28278
These directions are for planning purposes only. You may find that construction projects.
traffic. weather, or other events may cause conditions to differ from the map results, and you
should plan your route accordingly, You must obey all signs or notices regarding your route.
https://www.google.com/maps/dir/5850+Charlotte+Hwy,+Clover,+SC/12962+Waterthrush+Pl,+Charlotte,+NC+28278/@35.117072,-81.0679711,14z/am... 2/2

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