20191676 Ver 1_Shoreline Stabilization_20191209

r
Project
Owner:
PrintSignature
Contractor/agent: `r- /�' ,
Print v Signature
The approval is for tic purpose and design describes m your applicaiion. `Impacts not inuu:altd iii i-W
application is a violation of the Buffer Rule. Site specific work should be provided in the application. [15A
NCAC 02H .0506 and 15A NCAC 02B .0243(8)1
Trees are not allowed to be removed from lone 1 of the Buffer (within 30 ft of the full pond elevation), unless
approved. Exception, those trees that are severcly undermined along the immediate shoreline can be removed.
Minna! slm7mg and c,Vr mg, AiT � t'rrc *rmvx-.ILf,?4e <, Te,A is 2�,kewe�`� �?s �A NCAC 922A?�2a3(6)
Benching, grading in the buffer is not allowed. Excessive disturbance of ground cover. [15A NCAC 02B .0243
(6)]
Beaches, impervious patios, impervious walkways, ete. are not allowed in the buffer unless specifically
approved by the Division. There are limitation on size for decks. f 15A NCAC 02B .0243(4) and (6)]
Work to be conducted from land must indicate an access and indicate any trees that are to be removed. The
work corridor should be described. The approved access corridor shall be restored. Staging, spoil, construction
material must be outside the buffer. [ 15A NCAC 02H .0502 and 15A NCAC 02B .0243 (4), (6), (8)]
Stormwater cannot be piped or channeled for direct discharge to the take. All constructed stormwater
discharges must be at the tata-al elevaum and dischmoedi< Prior to entesiwg. the bul%r directed as dlifitise or
sheet flow at non-crosive veiociiies Io uid
Acknowledgement of Notification
1, — ))Ok� ` S �a n L o i u " ✓` . hereby state that I have been informed of the Catawba
Riparian Buffer Rule. Any work conducted in the buffer, not specifically stated in the application and approved
by the Division of Water Resources (DWR), is a violation and subject to enforcement. Due diligence will be
taken such that the construction will be built within subsiwitiul con;pl,wncc and inte-at of the 4o! Water Quality
CertificXaon. acid &YAW, . _ > tlh�e CANUTMd PUT(s) Vnd spcci.fi='on/;s), and other sapportng materials.
Signature (owner): / C Date: /t
AECEIVEAl E04P, CAAM
DEC 0 9 2019
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State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
Division of Water Resources 15A NCAC 02H .0500 - 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 be sent to:
Division of Water Resources
1
2.
401 & i3uffer.Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Applicant Information (15A NCAC 02H .0502(a)1
Owner
Name:
Mailing
Telephone Number:
E-mail Address:
Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http://www.saw.usace.arm mil/Porta1s/59/diatorv/regdocs/Permits/SAMPLE AGENT AUTHO
RIZATION FO_ RM. df) must be attached if the Agent has signed this application form.
Name: Q
Company Affiliation.
Mailing Address: -P
off! Vcrr _ J
Telephone Number':7oY_.3P__1-��.s
E-mail Address: M U_se'A d it /:.v
Person to receive the Certification Approval:
Fax Number -
GP :AM�-
Rn Az a -114
II. Project Information [15A NCAC 02H 0502(a) & (b)1
I. 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, etc.),
rip rap, excavation or dredging below Full Pond/ Normal Water Level elevations, and
FORM: SSGP 10-2013
Page 1 of 3

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 pr perty (where work is to be conducted)
County: _ Nearest Town: -f:e.uA
Subdivision name or site a dres (include phase/lot number): ___4W ,
Directions to site -please inc
l(ude road names a d numbers la dmarks, etc.:
Latitude (in dedmaldegrm)35 56152—$51 Longitude(dedmaldegrees)_ fi0.97%9Zg�
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):
6. Property size (acres): ___,j . o-
7. Lake/ river/ ocean adjacent to property: j Q,1 i9Q lh(hn
B. Describe proposed work (include discussio as to how har eninng of shoreline has been
avoided, or why it is necessary): ICI Q� DS<OitJ
9. Will work be conducted from land? Z From water? M
10. Total amount of disturbance (including all excavation, backfiil, rip rap, retaining walls, etc.)
elow the normal pool la level/ Normal Water Level in square feet or acres:
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: lia
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):
to // /,Ot r' e-M ova iNc �re-a
Owner/Agent's Signature Printed Name
115A NCAC f
02H 0502l)1 Date
'Agent's signature is valid only if on authorization fetter from the owner is provided.
FORM: SSGP 10-2013
Page 2 of 3

Full Pond/
Idorma�lAUge0, c
SlhoreIIne
ECG �yS
Lake
(At Full Pony!/Normal Vftteriavel)
© aocaoo oc
pow © oUa
I io'
3�5
I hC,00
� -SWUVW- OM
-LA�47 3
Please approximately sketch the following information on this plan (provide dimensions foreach
item, such os loft x 100 ft) *:
I. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
I 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.
S. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corridors
FORM: 55GP 10-2013 Page 3 of 3

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