20171485 Ver 1_Shoreline Stabilization_20171117

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State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
15A NCAC 02H .0500 - Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to: I<O'ktr At s L5 �j
Division of V11�er Resources V j
401 & Buffer Permitting Unit V
1617 Mail Service Center 1 7 201
Raleigh, NC 27699-1617 4DEQ_yyq T R P S UR S
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I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
2.
Name: kl_�
Mailing Address:
N 104-
Telephone Number: 10� 609-66k\ Fax Number:
E-mail Address: k r 30' o .Covy,
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/reedocs/Permits/SAMPLE AGENT AUT
HORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: 1 bt'\.L_ nes
Compal
Mailing
Telephone Number: 9a9 Na-,g20z(c> Fax Number:
E-mail Address: Lo( R ne, cov�l-mew l c..Q
Person to receive the Certification Approval:
H. 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, etc.), rip rap, excavation or dredging below Full Pond/ Normal Water Level
FORM: SSGP 10-2013
Page 1 of 3

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: llrtAh�ke_ VaAs C -
Subdivision name or site address (include phase/lot number):
5 Ot - Z>&t9, ��(� �� �n "A 5 `l 1 l i�>r�t c oafs , X 8 630
Directions to site - please include road names and numbers, landmarks, etc.: 1: -LAO W
Latitude (in decimal degrees)
5. Describe the existing land use or condition of the site/at the /gime of this (� l
application (residential, undeveloped, etc.): Voce -/A L�"� ( , -r' I t `vim � ` ,
6. Property size (acres): I - 5- k k AM9_S
Lake/ river/ ocean adjacent to property: `-P\e-
8. Describe proposed work (include discussion as to how hardening of shoreline ha
been avoided, or why it is necessary): T I v �� d
U Ic It N a ! /� c � s �{^C�C` • ✓l � nCi v /<�` -1 el cc
Will work be conducted from land? 0-� From water? 0
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:
Pop
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the iionrial pool lake level/ Norma, Water Level and So feet land -ward
in square feet or acres:

12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to be impacted (nu—mbber of trees, for instance): �jc o 0c(
Owner/Agenes Signature' [15A NCAC 02H .0502(f)] Date
Agent's signature is valid only if an authorization letter from the owner is provided.
0 14 • iS ° «GP!n All . d„gram.vpn . M -c -ft Pc,.—Pe ,.n — r
xpme Insert oe*ps wwsuuom sex sea+ w.u. vn.. IasMlthe
s, t- A • I -%� !:_ I —�Il r:, areae^ D\1000 D SsnpeFn: 31Fna
jdReset - ,�,�. r � -L.l.� snipe C -L' ; Rem.,
Paso �..,. ,...,. se'�x- ..7 Onetc B i 4.6. C "•. Aa _. __r r. <.nn -c ei 1�{ } {} v Arrrge ryes mace Erect 4 sneer-
• CIIpOoarE Sfitlei FOM peragraph D,—.g EORmg
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1 (Rk
12 Cull
Lake
LILA (At Full Pond/Nor al Water Level)
Q�De'
3�GSr
�= Full Pond/ '� l
Normal Water Level�
Shoreline
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u F- -k c�u
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If�- �cernv✓r c�`n �Cc�S�
t! ✓ r E2/c + � �-
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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/ Norma 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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