20191569 Ver 1_Shoreline Stabilization_20191113

C 61 �15& 9
SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO.-------------- PLAN NO.------------ PARCELID:--------------------__-
y TV -NV, N\Ass�tr . ��� �r�� - --- -- �t , ► C
STREET ADDRESS:-----1------------------------------------------p---------
RECaVEMEWDWR
Please print: a `� a ►� d 16 0.0LY NOV 1 a,2019
Property Owner: ------- -------------- ---------------------------------------
V4&tor RS%Ourcc s
Property Owner:-------------------------------------------------------- poppnitift Section
The undersigned, registered property owners of the above noted property, do hereby authorize
----7-Vv - K t_r -, I----------- of ------- —,-----------
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address(if
o
(iff different than property above):
Telephone: ---33 u 511(.Q -1 Q A r
----------------
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature
-- -----------------
Authorized Signature
Date: ------1----1------------ Date: -----------
AA

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
D'WR
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Four copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
I. Applicant Information [ l5A NCAC 02H .0502(a)J
1. Owner Information
Name: Raymond Baker
Mailing Address: 2055 Meadow Lane, Graham NC 27253
Telephone Number: Fax Number: 336-684-1217
E-mail Address:
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/repulatory/regdocs/Permits/SAMPLE AGENT ALIT
HORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: Jeff Kirby
Company Affiliation:
Mailing Address: 3973 Dickey Mill Rd Mebane NC 27302
Telephone Number: Fax Number:
E-mail Address: Septica(@bellsouth.net
Person to receive the Certification Approval: Jeff Kirby
II. Project Information [15A NCAC 02H .0502(a) & (bJ
336-516-1241
FORM: SSGP 10-2013 Page 1 of 4

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,
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: Caswell
Nearest Town: Prospect Hill
Subdivision name or site address (include phase/lot number): 649 John Russell rd.
ProspectHiill
Directions to site - please include road names and numbers, landmarks, etc.: Hwy 86 turn
onto Ridgeville Rd. turn right onto Russell Loop Rd. turn onto John Russell Rd. Property is
at the end of Rd.
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Residential
6. Property size (acres): 4.19 acres
7. Lake/ river/ ocean adjacent to property: Lake Roxboro
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Shoreline has been protected by a single wall
retainins wall which is failine. Existine wall is leanine and base of wall is rottinp, off.
Proposed work includes -removing existing wall, grading bank to a gradual slope down to
water.. Dlacine eeo-fabric 4' above pool extendine to 1' below cool level and stabilizine
with #2 rip rap. 35' ad j6y\im3 tt,%5V%r) � rcnStr►�Ct cti d��ab(Q.
w C,-k\ W uVre, b r-A-cJ-V— � e r- CT-05 i o n
-5kope. .k bcunv- S o.h1 iizo.a i>4 V-p0.br��C-
9. Will work be conducted from land? X9 From water? ❑
FORM: SSGP 10-2013 Page 2 of 4

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:
1000 sguare feet
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
wails, etc.) above the normal pool lake level/ Normal Water Level and 50 feet land -ward
in square feet or acres: 5000 square feet
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): Area is clear of trees
and only has grass to be impacted.
KICUr, y Cz-w
Owner/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 10-2013 Page 3 of 4

0
35%
axg"x$'
dad
a
(g-a-
� 5 C1 aA-r
r 0.�
�'r c
.Q
61 \J4 de- \NC,\ l
$IkpporkQ-d
,arc 2 x 8
hoar d5
00 floor bxo-goLbrc e.
v e,r¢, d b`
2 ri P rXf
pve� hr✓o 4 i Q v4 D F v4 o ye.
hreo�K v,tall
Fra,Me" �xls"
toyexo
.r- detVYx� boo.
,� 1),4 lk'
M.

����2®�� y\\
��� ^ -� \:�
� « < .� 2
\� \� = � ��
}����\/\�\
«/\� /:\ . T \
� �� © � � � �
� 3r2 �
� \:.: ._2
,� d � .:y :
f�.� . . �
© ��w ±»\
?..� � ��

J,�,'Y,� �!�' .� ram"'
Y � ; W
'1i y��i;Y j, f., �'Y Y i rS
d� � ,}, ,Y
4.-r��i�' . .
.fMf 1Y Y�.��tA��f/'I
�.
�i/._��
`��� �
. _ .. r ��.�"�'

+; 11�YY [y S:Y�� �•t M` `', f4 Y�4;1 4 Y k'),. . .1�/ +\.\,.1
y4%,!
1ki
+`4 e
l� r
�,p,• . � -vim' �.�4 +•

r s�_