20200227 Ver 1_Shoreline Stabilization_20200211

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02N MW — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 02-2017
Shoreline Stabilization Application Form
Three copies of the application (including attachments) anteGca{ion fey should be sent to:
!f sending via US Postal Service if sendingVia delitide " * rvice (UPS, FedEK,. etc.)
Karen Higgins Karen Higgins _ €�' c`
DWR — 401 & Buffer Permitting Branch DWR — 401 & Buffrermitting Br
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604 �� 1 ti0tio
A. Applicant Information f 15A NCAC 02i- .0502(C .1
1. Owner information off" vc'
Name: e�2 A d- V. r n+ �
Mailing Address: IG Z'l Q . � �-
�r�• s 1 aL 7_FD`1 `•i
Telephone Number: -7 o q . -i y i - -5 1'3 Fax Number:
E-mail Address: Srv\+'an r\ cr 2 Q I 4. ( , C__I> M
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:
'i LN VvVI ' SaiSr LSBC ri77�i it l%�Ci B uocs/rc-gulatC^r!, egUocs/Permi 15AiMPLi_ AGENT AU7HORIZ
ATION FORM.Pdf)
Name:
Company Affiliation:
Mailing Address.
Telephone Number:
E-mail Address.
Fax Number:
B.. Project Information MA 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, 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

•3. Attach a Okftgraph of the shore&W buffer proposed to be stabilized. (kx*x e a scale of
some sort a Yard stick, shovel handle, etc.)
4k Location of the property (where work is to be aorKductied)
County: Mont o Nearest Towrc �-. : le c
Lake/ river/ ocean a4ieent to property:
Properly size (acres)' .5
subdtridm name or sloe address (indode phase/kit n mber): S i-
bkecMns to site -please include road cremes and numbers, landmarks, etc.:
ladb ide (in d ecknd dew t,onetude (dlecknd deges)
S. Desat a the existing Iwd use or condition of the she at the time of this applicalJon
(residen iat undeveloped, etc.). ?-t s`je'A • j
6. Descrl a proposed work (indude discussion asto law harderang of shoreline has been
or why It is y):
7. Will work be conducted from land? From water? []
& Total amount of impacts belaw#he ran al pool lalxe level / Normal Water level
Permanent impacts (including A exannU n, bacM. rip rap, reetilrft waft etc.) In square feet:
Zzol- 10-O e 100
Temporary impacts in Square feet:
9. Total amount of impacts alrore the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (ineluding back fill, excavatiom rip rap. net Ill M wags,, etc.) in square fleet:
Temporary Impacts (temporwy dearft oonsauction corridor) in square feet:
20. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50
feet landward to be impacted (r mAw oftrees, for instance): 5e a, P f.s Otg v . Ag-j
IL SI=
Owner/A®enes, ! [15A NCAC 02H .0502MI Date
Agmft stgnaevr 1s v&W only Jyan auth k artk kUer from dw owner Is provided
FOMA: SSGP o2-2017 Pace 2 of a

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
A Pond/ Normal dater
Shoreline
Plan View
FORM: SSGP 02-2017
Full Pond/ Normal Water L
smvi�smaa
IRaLSOh
aa/lbndeiriit
Plan View
Lake
(At Full Pond/ Normal Water Level)
Lake
(At tall ftw Mcf w V"LL Lard)
Exisdng Dock
/3Ghx7h
3ha3mk
ML=r =
4*XMR
Page 3 of 4

Lake
(At Full Pond/ Normal Water M
/ io —
E E
O O
z in
c
Side View
M
3 ft. below full pond water level 4 ft above full pond water level 2 ft. additional clearing
`lf necessary
Existing bank
10 ft. bank a
height pyP'
FORM: SSGP 02-2017 Page 4 of 4

Survey for GERALD AND VIRGINIA TANNER
Rgxntyof KEVIN P. GARRISON and OTHERS
Subdivision SWIFT ISLAND PLANTATION
Lots) 41 PLAT CAB. E SLIDE 10—A
Tax Parcel 6575-07-68-0360 DB 624 PG 300
Street Address 205 WATER OAK WAY
Township PEE DEE County MONTGOMERY State NC
is
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VICINITY MAP (NTS)
'PR"a MAP MAY NOT BE A CERTIFEO SURVEYAND HAS NOT
BEEN RENEWEDBYA LOCAL GOMRNMENTAGENCY FOR
C0601REGULA�TIONSA'ANDHASN�OT�R I°WEDFOFOR°PMEM WATER OAK WAY
COMPLIANCE WITH RECORmNG REOU4tEMENTS FOR PUTS.- 45' RIV
PAYED 21'f EP-Ep - - R/W
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EP
137.66'
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1/2` EIRo- (T1E LINE) —ET e b FLUSH w
FLUSH FLUSH
BRENT A. BREWBAKER
DB. 550, PG. 682
LOT 42
TAX REF_ 6575-07-58-9277
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LINE LEGEND
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ry I ANDRE VAN DER WESTHUIZEN
•° r I I (ilE LINE) DB. 598, PG. 630
�o S07.1514 E LOT 40
50' �y?, gg.66 TAX REF. 6575-07-68-1278
LEGEND
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{ EP-EDGEOFPAYEhEM
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TAKE TILLERY- 1 BUILDING SETBACKS SEAL 9�
j 3U............ FRONT
IU..............SIDES Z c- r L-3883 3
10'..............REAR9�Y0
180' REVISED 10122102019 �N SUR4
ADJUST HOUSE LOCATION TO ALLOW '•.,,••Gq•1N••VL�.••
FOR 18"± ROOF OVERHANG.
GARY KENNEDY
PROFESSIONAL LAND SURVEYOR
(910-220-2557)-(910572-1708)
dkisl§embargmab.com
703 Page Street
Troy, N.C. 27371
Scale: 1"=60' Date: 9/13/2019 Precision 1:10,000+
Drawn: JGK Chw*ed: 9k Job: S-06919
I efftw that thb asp ti erase ®dr : Ltam .n -AmW
a w er aadm rmdr or aaprsYea (dad daaeewUms raaada I to Beat
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This map does not meet N-C.G-S.

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