20191575 Ver 1_Shoreline Stabilization_20191113

DWR
Division of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Watecarces
15A NCAC 02H .0500 — Water Quality Certification, Shoreline ab'ition
FORM: S P 16-2013
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
I. Applicant Information [15A NCAC 02H .0502(a
1. Owner Information
Name: I V Oq
Mailing Address:
Coy ouc ro ry , LA 32,133
RECEIVED DENRiCVVVP
NOV 13 2019
Voter I ssourcx;s
Permitting Section
/OIt�K��
Telephone Number: Q&S-705- 2Z71 Fax Number: '18 S - $39- C760
E-mail Address: Ci ma GeQ a� fVlagee law fi rM , tiet
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/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:
II. 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: SSG 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: .1 Sow Nearest Town: C5%e/S� I fVC
Subdivision name or site address (include phase/lot number):
Ic
Directions to site - please include road names and numbers, landmarks, etc.: 'FROM Ca h;eesi
NIC , --ta kc A&A, WIN +o Pi rJe Crleek And, l ef4 w /U, lUa r+ory 4 b,T ad
Sera41he0'r A,'lI d C d V �/1,'{n CaNfi/VLte Al, lllor r R►D �'�►,cu
tin rset .s h oe .. v v e ,tea s-f' r3' rzoKe v 06K, 1 e �1- do /V lewiaru 1-N, !1 c�nd
r q 0 oC
Latitude (in decimal degrees) 35 5b� Longitude (decimal degrees) r D�+ 1-106,
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): (An Je ve In p e
6. Property size (acres): q. S i acites
7. Lake/ river/ ocean adjacent to property: Ice Qeiyyi I I e
8. Describe proposed work (include discussion as to how hardening of storeline
has been
avoided, or why it is necessary): r
9. Will work be conducted from land? ❑ From water?
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:
3boo s -Ff-
11. Total amount of disturbance (including all c earing, 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: k.j W & , ft
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): j (p � S
—� i� M 3 f ` , in 5 RY k6S
,"-/4),f �,) 11r1 I DcAnet-.
Aa Ma - cIry Cove, LLC GCS- 25 Z 9
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 2 of 3

La ke
(At Full Pond/ Normal Water Level)
Fi
Norm
S
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft)*:
1. All proposed vegetation 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.
5. 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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FOR SHORELINE STABUTATION ACTmTIES M,%Y, 19%

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