20191591 Ver 1_Shoreline Stabilization_20191119

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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 ©UAL;ry 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, Fed Ex, 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)]
1. Owner Information
Name: Jon K. Little and Samantha O. Little VEit7/Q�f`N.���t�
Mailing Address: 2304 Furlong Place AIl11i
Eastover NC 28312019
Telephone Number: [phone] Fax Number: (910) 339-242%!�__ k ReoWces
E-mail Address: [e-mail] '�UEW1$ sectlop
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 does/regulatory/regdocs/Permits/SAMPLE AGENT ALITHORIZ
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.
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
Person
Nearest Town: Semora, NC
Lake/ river/ ocean adjacent to property: Hyco Lake

Property size (acres): 3.36 acres
Subdivision name or site address (include phase/lot number):
2 Clearwater Ln
Directions to site - please include road names and numbers, landmarks, etc.: Starting at NC
HWY 119N, turn right on Cunningham Rd, right on Franklin Rd, Left on Heritage Harbor Dr,
right on Clearwater Ln, 1/2mi on right
Latitude (in decimal degrees) 36.514986 Longitude (decimal degrees)-79.070523
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Residential lot -undeveloped
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Installation of riprap along shoreline to prevent further
erosion of land
7. Will work be conducted from land? V 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:
2500sgft
Temporary impacts in square feet:
3000 soft
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:
1000 soft
Temporary impacts (temporary clearing, construction corridor) in square feet:
3000 sgft
10. Please describe the vegetation above the normal pool lake level/ Norntlal Water Level and 50
feet landward to be impacted (number of trees, for instance): Brush and saplings will
only be affected; mature trees will be left untouched unless dead, dying or leaning
11. Signature
Owner/Agent's Signature* [15A NCAC 02H_.0502(ffl Date
Agent's signature is valid only if an authorization letter from the owner is provided.
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.

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)
k
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Plan View
Lake
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Existing Dock
Full Pond/ Normal Water
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FORM: SSGP 02-2017
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FORM: SSGP 02-2017 Page 4 of 4

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