20180245 Ver 1_Shoreline Stabilization_20180219

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State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Water Resources 15A NCAC 02H .0500 —Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL QUAL? FORM: SSCP 02-2017
Shoreline Stabilization Application Form PAID
Three copies of the application (including attachments) and the application fee should be sent to:
If sending via US Postal Service If sending via delivery service (UPS, FedEx, etc.)
Karen Higgins Karen Higgins
DWR — 401 & Buffer Permitting Branch DWR — 401 & Buffer Per
1617 Mail Service Center 512 N. Salisbury Street v
Raleigh, NC 27699-1617 Raleigh, NC 27604
rFE811 9 2018
A. Applicant Information [15A NCAC 02H .0502(a)]
1. Uwner
Name:
Mailing
Telephone Number:
E-mail Address:
2. Agent/ Contact Person Information
Fax Numner:
A signed and dated copy of the Agent Authorization letter must be attached if the Agent has
signed this application form. (A form can be downloaded here:
http://www saw usace army mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
B. Project Information 1`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, buildings, retaining walls, docks, impervious surfaces, 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.
FORM: SSGP 02-2017 Page 1 of 3

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 proper y (where work is to be conducted)
County: O Nearest Tow
Lake/ river/ ocean adjacent toproperty: el
Property size (acres): Ac7e,-,7e,
Subdivision name or site address (include phase/lot number):
Directions to site - please incluAroad namSsenofrumbers, landmarks, etc.:
Latitude (in decimal degrees) Longitude (decimal degrees),
5. Describe the existing land use or conditi of th/si-(atffi a t' a of this application
(residential, undeveloped, etc.): '
6. Describe proposed work (include dis ussion as to how
avoid d, or wh it is necessa ): -VG i'
P14-52
7. Will work be conducted from land?
of shoreline has been
From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent imp/acts (including all excavation, backfill ip rap, retaining walls, etc.) in square feet:
`%.YAao'
Temporary impacts in
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (includin$,back fill,
3J-/e_,G
rip rap, retaining walls, etc.) in square feet:
Temporary impacts (ter
,pporary clearing, construction corridor) in square feet:
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level
feet landwXd to be impacted (number of�fees, fonstance)/ /L�s
11 Signatu e
O ner/Agent's Signature* [15A NCAC 02H .0502(f)] Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 of 4

12. Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
Full Pond/ Normal Water
Shoreline
Plan View
Lake
(At Full Pond/ Normal Water Level)
FORM: SSGP 02-2017 I plan View
A M P IL cL.:
Page 3 of 4
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Full Pond/ Normak Water Lemo
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ii necessary
FORM: SSGP 02-2017 I plan View
A M P IL cL.:
Page 3 of 4

ICE
(At Full Pond/
5�
Side View
10 ft. bank
Side Vi
FORM: SSGP 02-2017
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3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
"if necessary
Existing bank
AMPLE
Page 4 of 4

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