20191364 Ver 1_Shoreline Stabilization_20191007

Water Resources
ENVIRONMENTAL QUALITY
State of North Carolina
2 0 1 9 1 3 6 4 Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 - Water Quality Certification, Shoreline Stabilization
FORM: SSG602-2417
Shoreline Stabilization Application Form
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 Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information [15A NCAC 02H .0502(a)] RECEiVEDIDENRIDWR
1. Owner Infor tion /I OCT 0 7 2019
Name: 11 A f Of y( doW&I
s
Mailing Address: % i1/ w'- parmidina -qQGtIoA
Telephone Number: h( - "J"/ /, Fax Number:
E-mail Address: er yUhG -71hIC • C 0 M
2. Agent/ Contact Person Information
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.miI/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation: LA Kest 4C ( S
Mailing Address:
Nor a 1102 S
Telephone Number: qOq- Fax Number:
E-mail Address: &, /d LhL ml ids- ear'n,4e
B. 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, 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 property (where work is to be conducted)R{ 1
County: �Je-, Lq Nearest Town: ' 0 t:� CO-- Ac C�
Lake/ river/ ocean adjacent to property:
Property size (acres):
I- it ,C- —111 ft_-�
Subdivision name or site address (include phase/lot number)
Rt-L)&A- PLteli
Directions to site - please include road names and numbers, landmarks, etc.: HW 2 Y/2 7
_tA /C_ K - T //&Y v �k 40, ICS jeL_ P /-,i
Latitude (in decimal degrees) 35'2�S. 3' 8 Longitude (decimal degrees) 9b . 0 JfL11/ 22-
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): ;�Gsi 14ffiu f is /l
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): A�v4el• C S �6b, /, 1-c- �3'J
7. Will work be conducted from land? ®/ From water? ❑
8. Total amount of impacts below the normal pool lake level/ Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
5-e, x- 3 FY
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls etc.) in square feet:
n� N s, Til j Y23 4 3
Temporary impacts (temporary clearing, construction corridor) in square feet:
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 550
feet landward to be impacted (number of trees, for instance): / 7_4�_& fd 40e'
igna ur /�—
Owner/Agent's Signatur 15A NCAC 02H .0502(f)1 ate
"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
Lake
ke
e(At Full Pond/ Normal Water Level)
0 U
\ 1
Full Pond/ Normal Water
Shoreline
Plan View
Full Pond/ Normal Water Lev
""Ihorerine— —
]ft.a 150 h.
additional clearing
if necessary
Plan View
Z� ly
Lake
(At Full Pond/ Normal Water Level(
Existing Dock
� �C„' �f �l'►t �4.��'
3ht 150 ft
RI ra
P P
aalMfuUMWNWL
4hy 150 ft
lull
�1 �I,�,7/, }/— /►�Q
Above
pond/ N.AMPLE
12 T64 4
FORM: SSGP 02-2017 Page 3 of 4

Pr FCS C,&
r„oa-L l vvc
a
J
Lake 0
(At Full Pond/ Normal Water Level)
f-) A
Side View
LL -
10 ft. bank
Side Vi
V(9
6 C) o
D �1
U O o
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
'if necessary
Existing bank
✓ 6
QO
Quo
FORM: SSGP 02-2017 Page 4 of 4

SAMPLE AGENT AUTHORIZATION FORM
pRCP;:R-'y LEGAL DESCRIp'IGIti;
LOT NC. I % PLAN NO. PARCEL ID: 0S7(0C) 33 9 3 2 � S
s w,EEt ADNESS: q q Cf (-�( .?=i v 6.1V 2d
- ) bVM&G 1 c t JG .2� D � i
propertyo, '� N c— I e6 A- O A-cl%o k ry
Property Qwner
rte Lrt(1Q►W-Wed, regis—eu pr�xriY Vw a of lt+e sLxv r._ e7 prupe- do htreby author
C� Azad -
(tjorttractar ! ,,,ger,;; (Name of cansLAWS,9 firm.;
to ac -,on my renau a; �d zake a4: acini necessary for t e p-«essing, is&,anc anc aa p nce of
tha5 perr:tit or ce Rtatior and any ane all star4ara and special mrtdit .5 attac*�ed.
property Owner's A —ess T different mar, proQerty abc,%'e);
?S-4 I T.trS+ leC�-K 0 S�Awf- c& -a Y'jZ. 273
Taiephone
hLaret,) `� me above nformaticn subMned in " appiicatson is trs and accurate m the
best of our Kry vled '-
leg
AA&)orired Signature
Date: 7/� 8 11 -
ALfthomed Signature
Dam:

9/26/2019
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9/26/2019
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Christi Gallagher <[e-mail]>
Christi Gallagher <[e-mail]> Thu, Sep 26, 2019 at 12:51 PM
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