20191617 Ver 1_Shoreline Stabilization_20191125

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j. 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 Form2��
Three copies of the application (including attachments) and the application fee should be sent 4
If sending via US Postal Service If sending via delivery service (UPS, FedEx, etc.
Karen Higgins Karen Higgins
DWR — 401 & Buffer Permitting Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
DWR — 401 & Buffer Permitting Branch
512 N. Salisbury Street
Raleigh, NC 27604
L—
A. Applicant Information f15A NCAC 02H .0502(a)]
- 1. Owner Inf ation
Name: Yco If
Mailing Address: 3
Telephone Number: / Fax Number:
E-mail Address: Avg 4j10VG , G4
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 mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTHORI
ZATION_FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number: MGEiIVE1X0ENP-DWR'
B. Project Information F15A NCAC 02H .0502(a) & (b)]
NOV 5 2019
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: 5SGP 02-2017 Page 1 of 3

At photograph of the shoreline/ I#Gffer proposed to be stabilized. (Include a scale of
fj i" rt- a yard stick, shovel handle, etc.)
p )perty (where work is to be conducted)
�',4TigWi?,,4 Nearest Town: P hC 0
LaKe/ river% ocean aajacent to property: -Al/CkoRY
Proper. We (acres; a• S
Subdivision name or site address (include phase/lot number): Oyftl/945 11412LO&W
Directions site - please include road names and numbers, landmarks, etc.: 83?
�Vf L NL J
Latitude (in vecfrr?o(ue�feaSJ ' 7$9'%0L ongitude (declmul degrees) 8�.3Y694 `
5. J>crMribe the 't, ;in,,e of this application
residenti,G✓I/
6. Describe proposed Wbrk (include discussion as to KF)w hardening of shoreline has been
voided, or why it is necessary): IINA&Ai1OStV�J
7: Will work be conducted frbm land? ED FFdm wAter?
YM
8. Total amount of irfapacH below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavation, backfili, rip rap, retaining walls, etc.) in square
feet:
1-emporary impacf4 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:
Temporary impacts (temporary clearing, construction corridor) in square feet:
10. Please describe the vegetation above the Mormal Pool lake level/ Normal Water Level and 50
feet landward to be i--_acted (number of trees, for instance,: WoO&V_& 5-i4QudS
�( 11. Signa
Owner/Agent; fi 15A NCAC 02H .0502(f)1
Agent'ssignUtt;,< is Valid
12. Please approximately sketch the following information on this plan and provide dimensions
FORM: SSGP OZ 20' ;a e Z of 4

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Parcel rD: 3'0406480638
LRK'RE;D: 600056
833 36TH AVE PL MV
HICKORY,28601
EVERETT DAVID K R
Acreage: 2.56
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