HomeMy WebLinkAbout20180350 Ver 1_Shoreline Stabilization_20180309State 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
PAI
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
Raleigh, NC 27699-1617
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: UJ UII" rr► J. Sf 6#7'YS
Mailing Address: J105 CI m40,k0A/ CJPCf_p=
UR/4- curOy EL JSS209
20180350
Telephone Number: 9yl 6c/r"2(o&O Fax Number:
E-mail Address: WSc1�,?tjr (4)lcahoo, Corn
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: /off /%f�2 7'iAl
Company Affiliation:
Mailing Address:
;r3a,c3 S ,0d CkcS c 6 C v
/-7, 0. ,Som so y
Telephone Number: S'z� Z26 -20 V7 Fax Number: gL& 7y�- 6 Z/6 O
E-mail Address: C�"_�.*o S6 u.n / , ec, --,
Person to receive the C rtification Approval:
I1. Project Information [15A NCAC 02H .0502(a) & (b)] RECEIVED
1. Attach a vicinity map (i.e. street map) clearly showing the location of "cMrith
respect to local landmarks such as towns, rivers, and roads. pENR.LAN0 QIIAL
2. Provide a detailed site plan showing property boundaries and praI.
IYIt�1ltG
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: A� -eoA l Nearest Town:
Subdivision name or site address (include phase/lot number):
732 /+��,I-11194+ _Wa46s . S
Directions to site - please include road names and numbers, landmarks, etc.:
To 6,-Y3-/ e - % � A`7 3 2 d ") Z_"C f� L / , / ,j
Latitude (in decimaldegrees) 3� /7� Z Longitude (decimaidegrees) —O-� w 77 03(5
S. Describe the existing land use or condition of the sate at the time of this application
(residential, undeveloped, etc.): _ /70i''1Sr Sf/
6. Property size (acres): 7` — ASC !F-
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):
S% t�jZ�f-�ty�1
1*1fiCcll
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 npr�mal
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 gool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres:
�6
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to be impacted (number of trges, for instance):`-
Owner/Agent's Signature [15 NCAC 02H .0502(f)] Date
Agent's signature is volid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3
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