20200128 Ver 1_Shoreline Stabilization_20200122

State of North Carolina
DWR Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources
FORM: SSGP 30-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the applica ' I e sent
to:
Division of Water Resources
401 & Buffer Permitting Unit 7 . ✓ �� N '
'r 1617 Mail Service Center oa s
Raleigh, NC 27699-1617 D o uF RµP
Applicant Information [15A NCAC 02H .0502(a)]
Owner Information
Name:
Mailing
Telephone Number: 76g-281-310- Fax Number:
E-mail Address: be.Ir4'SfVk6 r}(y A 4 rNa,t'"M
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
htti)://www.saw.usace.army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.odf) must be attached if the Agent has signed this application form.
Name: I�c�izL (.4wv/Sc Anc_ Sb�LUica=3
Company Affiliation: L_4t4, .i
Mailing Address: �x '7of3
?Av,j ( NG. i3o—o-7a$
Telephone Number: 7oV-SL3 -bZ07- Fax Number:
E-mail Address: /fir ,,, w, .. ! Ac> /`fit , e.",l , C-44 t
Person to receive the Certification Approval:r>tivkc
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.
7 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: NMe4,1c�v& 4 Nearest Town: G(1,a-r10We—
Subdivision name or site address (include phase/lot number):
mt Po: of
Directions to site - please includeroad
Jrroad nam�e^s and numbers, la�n)dmarks, etc.: ,J
iV
vMA_ICY_ n f i 611% +- n n l AA — 4-10-kP_ /fPF AA4-0 /'t'9 'r-A 0-3 -'Y ✓L.
Latitude (in decimal degrees) 3S 34 Longitude (decimal degrees) 'OD, l as 5'
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): �-_e_5; cQGyt iio
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property: fM fi.
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
9. Will work be conducted from land? � From water? El10. 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:
10
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: -000 S. IV -H
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):yo -0
06"K h,i tlPa�(IST�ass slope-
Owner/Agent's Signature 15A NCAC 02H .0502(f)l Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Lake
(At Full Pond/Normal Water Level)
Full Pond/
Normal Water Level
T����
Shoreline •
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.
5. 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