20150181 Ver 2_Shoreline Stabilization_20191014

State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
Division of Writer Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
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 RECOVEDt9El DWR
OCT 14 2019
1. Applicant Information [15A NCAC 02H .0502(a)] Watar Raxourres
1. Owner Information Permitting S cticxi
Name:
Mailing Address:
q9'2
Telephone Number: �`i3• y2Z,0��� Fax Number:
E-mail Address: beirrrA\Y\e_S(ovelW UAhierSn ..Cvm
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.armV.miI/Portals/50/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:
E-mail Address:
Person to receive the Certification Approval:
Fax Number:
11. 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: S 6h, Nearest Town: COA&o-_5
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (in decimal degrees) 3 S• t W Sao Longitude (decimal degrees)
- 13.1 43` 1 X
5. Describe the existing land use or condition of the site t the time of this application
(residential, undeveloped, etc.):
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property: lab G LmV1
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):e'�b�o\hl S�i��o1�i.1Un V,St
9. Will work be conducted from land? ❑ From water?2T
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal lake level/ Normal Water Level in square feet or acres:
1po
Sq
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: t 00 �t S4.
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):" [ S a1_2Q\rC
° art 4.arr,,_bs
Owner/Agent's Signature* [1SA NCAC 02H .0502(f)] Date
*Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

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Please /approximately
� s�jk. eytch the following information on this plan (provide dimensions for each
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1. All proposed vegetations 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.
S. 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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