20191662 Ver 1_Shoreline Stabilization_20191205

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. v� A LAN NO.
T.A10
PARCEL ID:��Q�A 4�
STREET ADDRESS: 1 7 11 rl OL�sQ 1V D%Ce-
ccrirn -I i u-, N C 29-o3J
RECBVEDJ©EtNDWR
Please print:
Property owner: �l��sukL,�u ( �M,� o�c i<� QFc 0 5 2019
Property Owner: V i lct ' ntC cd1a.) t•r Resourcks
Prrmittr'19 54 000n
The undersigned, registered property owners of the above noted property, do hereby authorize
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 different than property above):
Telephone: --10 4 -
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
-C'.' CNwu AL2J ICL
Authorized Signature Authorized Signature
Date: Date:

'D
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Water Resources 1SA NCAC 02H .OS00 — 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, 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: 1 � O � a.
Mailing Address: 1 d SO 0 S4DU(I i
Un-Z6'7\ eA 1LL S M C 2cl� V3 1
Telephone Number. 'D" --6 D -_ISS Fa Number:
E-mail Address: � a ���l \ _
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 AUTHORIZ
Name:
Company Affiliation:
Mailing Address:
Telephone Numbe
E-mail Address:�-
:ax Number:
B. Project Information [15A NCAC 02H .0502(a) & (b)]
1. Attach a vicinity map (i.e. street map) clearly showing the location 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
1�

Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale of
some sort- a yard stick, shovel handle, etc.)
4. Locatio Hof the roRertwhere work is to be conducted
County` \ \ \l'- n��v-� Nearest Town:
Lake/ river/ ocean adjacent to prop
Property size (acres):
Subdivision name or site address (include phase/lot number):
Din ctions to site - please include road n mes and numbers, landmarks, etc.:`
Latitude (in decimal degrees) '` Longitude (decimal degreesr!t��
5. Describe the existing land use o"r-:pndit\Qn of thsite t the time of this application
(residential, undeveloped, etc.).
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 4�d n-eezb kj
r..-,-a
y✓ c--�j
1l� �'�ww i r9rtcti� S%—f4 r��Kr-A/�1I trG-�. L�'-✓vl���uJ L, dy.�a Ale /^`� �/
Sk,y/t b4,.icr-�'C. -c-c�►rr�c alc4c� �--r,u/M/�S Srt�t-4�c cv =Tc� t •Q�-r� �t.ec��Zcif ,
7. Will work be conducted from land? From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent i pacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
7/ 20 .5-9f
Temporary impacts in square feet:
C)
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (in�luding back fill, excavation, rip rap, retaining walls, etc.) in square feet:
Temporary impacts
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): c��� i'sSSy l/•
11. Signature
Owner/Agent's gnature' [15A NCAC 02H .0502(f)] Date
'Agent's signature is valid only if an authorization letterfrom the owneris provided.
FORM: SSGP 02-2017 Page 2 of

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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 orfill 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)
0 w.--
r
Full Pond/ Normal Water Level
Shoreline Cp U C5 d CD
-216'---�I-----� �`—�
Plan View
Lake
Existing Dock
Full Pond/ Normal Water Level
— — — —
.......Riprap..
......
If n-ry
E
AMPLE
Plan View
FORM: SSGP 02-2017 Page 3 of 4

3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
'If necessary
Existing bank
10 ft. bank
Side Vi
FORM: SSGP 02-2017
Page 4 of 4

11 /25/2019 Stough Farm Rd - Google Maps
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Map data ©2019 1000 ft ■ ■
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Cornelius, NC 28031
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