20191665 Ver 1_Shoreline Stabilization_20191205

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State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
Division of Water Resources 15A NCA i �o — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should lsent
to:
Division of Water Resources OF
401 & Buffer Permitting Unit �� ®
1617 Mail Service Center
c'
Raleigh, NC 27699-1617
1
Applicant Information [15A NCAC 02H .0502(a)]
Owner -
Name:
Mailing
E
Telephone Number: (. k)464-6300 Fax Number: J��) 413-Q15_3
E-mail Address: • , • ('1
2. Agent/ Contact Person In ormation
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/reedocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.0 ) must be attached if the Agent has signed this application form.
Name: Z?0,1�S 5i✓J 7W eO ./ tiXAe f'-*,0 1—^
Company Affiliation: ,4'Df' /%
Mailing Address: f% d - f3�fG" 30
��73
Telephone Number:Fax Number: ��'-"��/3-�Z--�•�
E-mail Address: B CL, vex Cp'o-&/. "e7­1
Person to receive the erti ication Approval:yT3/,19�z4 4
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: SSGP 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 roperty (where work is to be conducted)
County: ,�''C��l Nearest Town: 72-9%70A�l14'e,
Subdivision name, or site address (include phase/lot number): ,��9�►'r�/����/�r�1�9z�—S
Directions t=te - please include road names and numbers, landmarks, etc.:
,,�//�
Latitude (in decimal degrees) 3S_ Z71,9t(o Longitude (decimal degrees)'—�, �o� 749
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): /M� /z'Y Worry'F-s/i'6 AXIJ- Z�C-
6. Property size (acres): / -f - "-�-e/Z 9-
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): % S/i3�G1Z� S�D��GfN� �ivDSTtfP
9. Will work be conducted from land? ❑ From water? X
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:
'ev�o se'
11. Total amount of disturbance (including all clearing, 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:
_> a
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): /y0 /.L
2g�VVt1,,4,p�i
Casa
Z'hudru 8, !
0 ner 's Signature` [15A NCAC 02H .0502(f)l Date
"Agent' signature is vagrnha^
d only if an authorization letter from the owner is provided.
CAgent',; ilC'rri%.t"'
C RM: SSGP 10-2013 Page 2 of 3

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