20200074 Ver 1_Shoreline Stabilization_20200113

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State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
WaterResourCes 1SA NCAC 02H GS00 — Water Quality certification, Shoreline Stabilization
_::YAa OtL .F1i T:.i QUPaTY FORM: SSGP 02-2017
Shoreline Stabilization Application Form 40
Three copies of the application (including attachments) and the application fee should � � to:
If sending via US Postal Service
Karen Higgins
DWR-401 & Buffer Permitting Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
if sending via delivery service (UPS, Fe Fir �f
Karen Higgins
DWR-401 & Buffer Pe
512 N. Salisbury Street
Raleigh, NC 27604 lA V 1 3 2020
A. Applicant Information 115A NCAC 02H .0502(a)j
1. Owner Information
Name: (, h r, -r fiC., N n:j , LLG
Mailing Address: i?:g lax'a Gf
Al0 K'/aa/�n/l'Z,7.?oX1r
Telephone Number: 91n-5QL-?32f Fax Number.
E-mail Address: ILAkiIoo Dr Ja..lu.�+br�.com
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://wwwsaw usace.armv mil/Portals/59/docs/regulatory/regdocs/Permfs/SAMPLE AGENT AUTHORQ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number.
E-mail Address.
Fax Number:
B.. Project Information f15A NCAC 02H .0502(a) & (bl)
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: SSGP 02-2017 Page 1 of 3

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a. Attu a photograph of the shoreline/ buf%r proposed to be stabilized. (Include" a scale of
some sort a yard stick, shovel handle, etc.)
4, vocation of the property (where work is flu be conducted)
County: n2g4iQ=mr V Nearest town: 44 +. c. ,' Ma d�
Lake/ river/ ocean a4"t to pmpert :
Property size (acres)-
Subdue name or site address (include phase/lot number): -T4 A u
Directions to site - please include road names and numbers, landmarks, etc: See- M 8 0 -
Latitude (in dedmarl degrees) ,,,-2,?*�,V Longitude (deamd degrrees)- �•
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc): fe, S, ;Jp n4,' ) =
6. gibe proposed Work (include discussion as to how hardoft of shoreline has been
avoided, or why it -is necessary] SAr-e h'n0
7. Will work be conducted from land? '/ From water? Q
ti. Total amount of impacts blow the normal pool !aloe level / Normal Water Level
Permanent impacts (including all excavation, ba ddill, rip rap, retaining walls, etc.) in square feet:
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool Make level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including back fill, excavation, rip rap retaining walls, etc) in square feet:
Z)e 6c /2© t2Ff
Temporary Impacts (temporary clearing, construction corridor) In square fleet
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10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 5o
feet landward to be impacted (number oftnees for instance): Some- A, Prov.y&d
11. Signature
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owner/Agents Signature r15A NCAC 02H .oso2mi Date
Agent's.*natmm is valid only if an and iodtadon kn er from the owner is pMvided
FORM: SSGP o2-2M7 Page 2 of 4

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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 or fill 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
Plan View
FORM: SSGP 02-2017
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Plan View
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lAt Full Pond/ Normal Water Level)
Lake
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Page 3 of 4

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3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
necesary
Existing bank
10 ft. bank 2a
hei8ht oy
FORM: SSGP 02-2017
Page 4 of 4

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