20200106 Ver 1_Shoreline Stabilization_20200117

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State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
DlvWon of Water Resources SSA NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
, N ^ C' LvJ' FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: 1-0
Mailing Address:
N
Telephone Number: Fax Number:
E-mail Address: py1 . c( q j7 �0— (!�j O-0 O�
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http://www.saw.ulgcg.armv mil/Portals/52Ldogs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.odf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:Gir . D V
Mailing Address: Z
r;
Telephone Number: -X:>-A yiX3 k1 Zi Fax Number:
E-mail Address:
Person to receive the
II. Project Information [15A NCAC 02H .0502(a) & (b)1
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 30-2013 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 property (where work is to be conducted)
County: Nearest Town: AA r77) fv_S
Subdivision name or site address (include phase/lot number): 1 0+ l� Q
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (in decimal degrees) Longitude (decimal degrees)
5. Describe the existing land use or condition of they ,site( the time of this application
(residential, undeveloped, etc.): T-4 16 01�o�C
6. Property size (acres): . -5
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
9. Will work be conducted from land Ix
From water? ❑
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:
fJG0E,
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: P.),p O.F,
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
SO feet landward to be impacted (number of trees, for instance): [ S
Z
Owner/Agent's Signafure Printed Name Date
115A NCAC 02H .0502(f))
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. �_ PLAN NO, PARCEL ID:
STREET ADDRESS:
Please print:
Property Owner: 6w—`r''
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
(Contractor / Agent) ff(Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuanoe 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):
214 1 uSe �1�-, �a��d 1.lt,�tic ,� gZII
Telephone: 1 V 1 k —72 l
We hereby certify the above inform
best of our knowledge.
Authorized Signaboi
Date: LP 2 U
application is true and accurate to the
Authorized Signature
Date:

La ke
(At Full Pond/Normal Water Level)
Full Pond/
Normal Water Level
Shoreline
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft) *:
1. -A
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.
5.
1 Qration of Anif wrrAlrat;gn-or dredging below the Full Pond/ Nnrmal Vdatpr-LeveFeteyation-
6. Location of construction access corridors e
FORM: SSGP 10-2013 Page 3 of 3

LEGEND
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�DM,IS�
STATE OF NORTH CAROLINA
I. WD G POOaEY CEWIFY 1WT TMS WP WAS (DIWN BY ME)
(p UNCEP W SUPEIMSION) f (AN ACIWL SUR WCE
HY ME) (. .KIUIL SURY£Y M!DE U. MY 9NEIMSION,] 1 (GEED
DESCRITION PECCPOEO M BOON 901 ME 19J1
BOOR ,PILE : TC ,PILE
1Wi 1NE P OF PREC90N AS GL UUTED 6! UTRDDES AND
DEFF I RE IS 1: 1000 . (THAT THE SOUNMIE5 NOT SURYEIFD
ME SHONN AS &NNEN UNES PLOREO FROM WFORWTCN FOI
IN 000K 1♦ , ME W 1: TNO, . Y.V WAS
MMED IN KCONDWCE MTIN C.S. 47-SO, AS NENCED.
WRNESS YY NNID AND SIX THIS THE Dlm MY
tWE99]YL 1N0 9MF.A1 - RE E]IH OF oOFLMBER 0FIz ku 9iO
e r r e
��r4r-m
M.P
DEDMON SURVEYS
MTE DEDEYBEN 3, 2018
SCALE lY 30'
DB: 901 PO: 1933
DB: PO:
PB: 14 PG BO
PHYSICAL SURVEY
FOR
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SITE
OBOYON SURYBYB
CHUCK POOVEY, PLS #3762
ROBERT DEDMON, PLS #3899
3704 NC HIGHWAY #16 BUSINESS NORTH
P.O. BOX 494 - DENVER. NC 28037
PHONE: [phone]
FAX: [phone]
DAVIDSON TOWNSHIP
IREDELL COUNTY, NC
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Ht1AlA\1DAA N Jh 1
AND LOTfA lETT
Au OF LOT 149 s ISO CRESCENT
u D MO TIMBER, SEETON 7
02M h 243 BWBER LOOP, YOORESVILLE, NC
SURD. W.. vi
ORAWFI: XPJ
JOBIF LOOP149

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