20191378 Ver 1_Shoreline Stabilization_20191010

r 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
ENVIRONMEN I AL QUAL 1. FORM: SSGP 02-2017
Shoreline Stabilization Application Form 2 0 1 9 1 3 7 8
(�N �
ee 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 R
1617 Mail Service Center 512 N. Salisbury Street ���w
Raleigh, NC 27699-1617 Raleigh, NC 27604 R�GVF 2019
OC1 1 �
A. Applicant Information [15A NCAC 02H .0502(a)] Resserce�
1. Owner Information Porm�riMng
Name: `. ct(y\eS -S6 CL'V4Arz\'
Mailing Addresso Lbivc, R o, La s j e -
Telephone Number: (x'13) y s. /-0-7c1 Fax Number:
E-mail Address:
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:
httr)://www.saw.usace.armv.mil/Portals/59/docs/reRulatory/reedocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name: _� c�„� L
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
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)
County: P.,Ae<4-0rd Nearest Town: �-ake Lone.
Lake river/ ocean adjacent to property: 1— o_kp, Lure—
Property size (acres): ,y o2
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (in decimal degrees) 35. y,9 �_lCP6 Longitude (decimal degrees) 15'), ) F ff )")
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): R e -s) Ae_,,j4► ..( (R-0
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): $Jb,aSe. �Il'( 4-oL Co,,4 ' 1v S%orAilve- Dr/ �e
�:. aprox), 6c, - 160 e_t�4 01 S ho- e(! C- �T Gi oBS Nab A&V C, CnSea�n�i _I f
' 1j�L71 DJSA_ C.�Nl�1 D vC�(4C W)ll ioe C-oiv6+-c4-d (:S)- drtr ' od d
Gi d � w0A ,
7. Will work be conducted from land? From water? ❑ W/ _- W )� uS c r FG
8. Total amount of impacts below the normal pool lake level/ Normal Water Level
Permanent mp ( cludin II excavation, ckfill, rip rap, retaining walls, etc.) in square feet:
goo a' -i'
Temporary impacts in s
t<ZeR0 /1
9. Total amount of impacts above the normal pool lake level/ Normal Water Level and 50 feet
land -ward
Permanent i pacts (including back fill excavation ripr ,retaining walls, etc.) in square feet:
Temporary impacts (temporary clearing, construction corridor) in square feet:
\1LZ'erb 11
10. 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): 2-ero 4ee4
► o ni Ly It. r' iw 61
ac..)r4
11. Signat _
er/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

AL Ste- c,�cllineA
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
(At Full Pond/ Normal Water Level)
Full Pond Normal Water Level
Shoreline -�
Plan View
Lake
(At Full Pond/ Normal Water Level)
Existing Dock
/3ofta7ft
E AMP E
Plan View
O'C eye
S ha
e -r6.5
i9a*r 20 N'e
FORM: SSGP 02-2017 Page 3 of 4
s
,--�-
P—Ab—
full pond/ NWL
M�itloral clearing
if nea,wy
E AMP E
Plan View
O'C eye
S ha
e -r6.5
i9a*r 20 N'e
FORM: SSGP 02-2017 Page 3 of 4

10 ft. bank
height
Side View
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
If necessary
Existing bank
FORM: SSGP 02-2017 Page 4 of 4

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