20061518 Ver 2_Shoreline Stabilization_20191106

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,. 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
ENVIRONMENTAL QUALITY FORM: SSGP 02-2017
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 fC'��
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A. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: o'
Mailing Address: 3 U o
ra—
n Pri F 0 3 7
Telephone Number: 76) 1J 7 76? �?6 7d Fax Number:
E-mail Address: Je-(.Cv
2. Agent/ Contact Person Information
�tK Kll souGtt4�
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/dots/reRulatorv/rep,docs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
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) �1
County: L11\ ( 0� n Nearest Town: r er1 Ver
Lake/ river/ ocean adjacent to property: A)&rlvt q Vt
Property size (acres): 1 6zCr'e
Subdivision name or site address (include phase/lot number):
S r
c,,54�,,,e\A c-(),o 104 i4=13
Directions to site - please include road names and numbers, landmarks, etc.: %V- cpn 6-"" re5 16�
(Z.y'1n� �,/� We�bS� �e��"�✓i P•15+wtss�� C�ov,.� Sri, � �,� f�ivP�t��fl k�i> , � �t°-� c,� t�l�� �%✓�� ice, �r✓iyP ��(c�'S:
Latitude (in decimal degrees) 630 7 Longitude (decimal degrees) ,fin q1?
Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): s 1(,(��� a
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 4 a44,( �� rG 1,2
10"A /0 /1"N1��
7. Will work be conducted from land? Z 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:
_5o r/ cam 4P
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:
Z(go S C/ "U
I
Temporary impacts (temporary clearing, construction corridor) in square feet:
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): Mv) ch , urP
5 c:M--e S'4n4 0 �� `f inet' S, $
11. Signature
Owner/ gVture
's Si
*Agent's i
re* [15A NCAC 02H .0502(f)]
Date
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
6,2''Irr V"AAM
(At Full Pond/ Normal Water Leve
Full Pond/ Normal Water' Level
Shoreline
I 1
P p64a w
I�p14 (�� ale O
I I ��
ul III 1�3"j� ti
Plan View
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FORM: SSGP 02-2017
Lake
(At Full Pond/ Normal Water Levey Existing Dock
30 ft $ 7 ft
3 ftx 150 ft
Below full pond/ NWL
Full Pond/ Normal Water Level
"Iho
eoreT'r rr —
®ine � akxasofc
Riprap Above full Pond/ NWL
2 ft, x 150 ft.
additional clearing
' If necessary
XA FM P L E
I i
Plan ViewE 1
Page 3 of 4

5 (6 re I s 6-00d
- t I a id A/e p,
a
La ke
(At Full Pond/ Normal Water Lever � Ln
0
C
Side View
ILI-
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
f necessary
Existing bank
10 ft. bank
Side Via
I
FORM: SSGP 02-2017 Page 4 of 4

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