20181512 Ver 1_Shoreline Stabilization_20181105

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:
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:
Mailing
20181512
NUV 0 5 2018
DE -WA ER RES UR ES
401 & BUFFER PERMITTING
i \ .
Telephone Number: r(ou- 3w - 9383 Fax Number:
E-mail Address: Aix nleu % r f3 n'_) nil. e_nvn
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:
Company Affiliation:
Mailing Address:
Telephone Number: rJO'4-6LP8-Sll( Fax Number: 7oq-(n(o0- 5CJU9
E-mail Address: b�� n►,c I l� + �'+nc1S�r �t rno o -E -
Person to receive the Certification Approval: Tanice,
II. 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,
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: P_c� �e n ra Nearest Town:
Subdivision name or site address (include phase/lot number): 159ict
l-i�n�ersv►e .1�1C a8 '1 �3 i- # �� .[1, o� 114'shore.S
Directions to site - please include road names and numbers, landmarks, etc.: "1 riI K
Laiiivae (in decimal degrees) -3n. y d,y, Ca Ll 1 Longitude (decimal degrees) - 80_. 4J 111 .
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):Re_s',rlen+iCLA
6. Property size (acres): . 505 a,cxeS
7. Lake/ river/ ocean adjacent to property: (4orma n
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 5ha.f� a.nd Linde- i nS_i L( -1-4-1 aQ
am r�rl5in �n� Ic°ler r'► s� rn n
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:
I
1-3 e A in ile
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres: ` ClJbc)\[e_
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): Q e .c 5'5 , F
i
Xowner/Agent's Signature` (15A NCAC 02H .0502(f))
lb -mag
/o - '�L;-- /d'
Date
`Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Full Pond/
Normal Water Level
Sho
reli'ne ''
Lake
(At Full Pond/ Normal Water Level)
1 10-bove
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IAo + ee5S re noveCl
r4o d i sou r bax►ck.
!Rale h E T CLn Do -in let
l5q lckl-. o jshore. Dr,
(-� � n-�-ersv'► tle � I�I.0 a 8 0'18
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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Polaris 3G Map — Mecklenburg County, North Carolina
Date Printed: 10/26/2018 2:36:51 PM
0 0.003).006 0.071es WE
S
This map or report is prepared for the inventory of real property within Mecklenburg County and is compiled from recorded deeds, plats, tax maps, surveys, planimetric maps, and other public records and data.
Users of this map or report are hereby notified that the aforementioned public primary information sources should be consulted for verification. MecWenburg County and its mapping contractors assume no legal
responsibility for the information contained herein.

10/26/2018
Go gfe Maps 15919 Bayshore Dr
15919 Bayshore Dr - Google Maps
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Go gle Maps 15919 Bayshore Dr
15919 Bayshore Dr - Google Maps
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