20180891 Ver 1_Shoreline Stabilization_20180627

O a 9 1 State of North Carolina
fir, 2 8 Department of ErWir� Int and Natural Resources
inion of Water Resources
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15A NCAC 02H .0500 - Water ification, 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: _
Division of Water Resources �/
401 & Buffer Permitting Unit
1617 Mail Service Center JUN 2 7 2018
Raleigh, NC 27699-1617 _
np A,,, -
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name:A- n(,�
Mailing Address: �3O
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14�2 IN cc, �C
Telephone Number: �u%1^/- I Fax Number:
E-mail Address: I e r i & P 2r_e C` % t_ C. r»"n
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/PoEtaIsdocs/Permits SAM ENT AU
0R17..A.R'_ndf) must be attached if the Agent has signed thi ication form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Person to rec ive the Certification Approval:
Fax Number:
II. Project Information [15A NCAC 02H .0502 a) & h)]
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 prttoperty (where work is to be conducted
County: (20—' C1\ J e.l Nearest Town: s- V'or,�k + e_ Fa, ( 1
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.: F j v
- r\ -
Latitude (in decimal
(decimal degrees)e10�
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): (,. CN e / ( f ea
6. Property size (acres): / O - b? `/
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): ` -L,, ►` i ►nom _ y-\
9. Will work be conducted from land? 0-" 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:
r --)n i . ":� CJI i_
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake levAl/ Normal Water Level and 50 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 (number of trees, for instance):
Own r/Age �reis
ture [15 . i . �E-�C 0=_U5,� X11 Date
Agent's s' lid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Full Pond/
Normal Water Level
Shoreline
La ke
(At Full Pond/ Normal Water Level)
CD
�GoNSr¢vcn.�//.
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/ 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.
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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