20200070 Ver 1_Shoreline Stabilization_20200113

of v.'/v
State of North Carolina
DWR Department of Environment and Natural Resources
�, _� Division of Water Resources
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15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: MP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the apF
to: l
Division of Water Resources
401 & Buffer Permitting Unit
I 1617 Mail Service Center %
Raleigh, NC 27699-161 /
I. Applicant Infonnation 115A NCAC 02H .0502(a)]
1. Owner Information
Name:
Mailing Address:
2
Telephone Number: 7 o 4n I. - tit) q i Fax
E-mail Address: -t- G 5 r? 2- 9, Ca-
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded
here:
htto://www.saw.usace.armv.mil/Portals/59/docs/reeulatorv/re2docs/Permits/SAMPLE AG
ENT AUTHORIZATION FORM.odf) must be attached if the Agent has signed this
application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Person to receive the Certification Approval:
Fax Number:
11. Project Information [_5A NCAC 02H .0502(a) & I ]
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,
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.
FORM: SSGP 10-2013 Page 1 of 3

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 property (where work -is to be conducted)
County: A i ey a ;Jd.-P r Nearest Town: % a g I c -I ill` /I -e-
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (in decimal degrees) Longitude (dedmai degrees)
S. Describe the existing land use -or condition of the site at the time of this application
(residential, undeveloped, etc.): o _Y r S r d- a; w e P i d d H
6. Property size (acres): za & re `>
7. Lake/ river/ ocean adjacent to property: 1_ it /� < ,(i r. V- y
8. Describe proposed work (include -discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 6Le �e . , d a ; nr a Ale L/v
L
9. Will work be conducted from land?
10: Totaf amount of disturbance (incluc
11 Total amount of.disturba
retaining walls,- etc) abo�
From water? []
all excavation, backfill, rip rap, retaining walls,
Norinal Water_Level=in square feet or acres
.all clearing;
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Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft)*:
1. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level
elevation
3. 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
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FORM: SSGP 10-2013 , Page 3 of 3

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