20200193 Ver 1_Shoreline Stabilization_20200204

20200193
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
V 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 02-204
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent to:
if sending via US Postal Service If sending via delivery service (UPS, Fed Ex,
Karen H
DWR-
1617 M
Raleigh,
A. Applicant h
1. Owner I
Name:
Mailing
Telephc
E-mail �
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:
lLt '//, Il''� r sar uc��- , P� �, 9 r r� ia':c•�.. -a UGCS/Perfr' =_—.PLE AGENT `.UTHORf-
ATION FORM.:,df)
Name:
Company Affiliation: i� i -+ J _� 4
Mailing Address: %� ^
Telephone Number:
E-mail Address:
-S�Fax Number:
ice? i _i r ! � i
B. Project Information [ ` HCAC 02Y .0502i;;' `> '_.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.
C aLe c Lcc
2. Provide a detailed site plan showing property boundaries and propo_,ed 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 torm.
FORM: SSGP 02-2017 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.)
Location of tTrpo,
roperty (where work is to be conducted)
County: r') V-) � 1, r1 Nearest Town: �C Lw ( 2
Lake/ river/ ocean adjacent to property: L a 1i-i P �Cc
Property size (acres):
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.: (<'Irn',n
5��z,c{h�i � (c'D n_,� �('nrc' jar: w �.c.�t"' T '; cuc:�,4'(��.sbn s,ka)
r
Latitude (in decimal degrees) �.�:Q/Z9cj / Longitude (decimal degrees) I L
5. Describe the existing land use or condition of the site at.the time of this application
(residential, undeveloped, etc.): Fe,3i d('.n f', QI
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): MCt�60, I G_ ,-, M(',(C, l:f �, Ce b C �—
7. Will work be conducted from land? From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all
Temporary impacts in square feet:
I, rip rap, retaining walls, etc.) in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
nt impacts (including-� back fill. t-y vation, rip rap, retaining walls
//,
Temporary impacts (temporary clearing, construction corridor) in square feet:
in square teet:
1 fD
10. 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): 1 J Trle(:�,❑
11. Signature
J
Owner/Agent's Signature' [15A NCAC 02H .0502(f)] Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 of 4

10 ft bank
height
Side Vi
FORM: SSGP 02-2017
3' Above I a`he 1 t�,j�
2 ft_ additional clearing
3 ft belowfull pond •.•star see el 4it aocve :uB pond water lode! • i{ recessa��
i
Page 4 gt 4

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1161

EXAMPLE AGENT AUTHORIZATION FORM
Property Legal Description:
Parcel ID: 3 3 6
Lot No. (if applicable) (0(,n1 _ _ Plan No. (if applicable)
Street Address (if applicable), ') 3n,/J�W66 t � �rit�`��M ��Ac--Z?2
Property Owner:
Owner Name (print):
Property Owner's Address (if different than the above):
A!�(o LA^v4'Lt U"41 w-11,aw SP �g CtiG a S�
Owner Signature: t
—&
The above registered property owners of the above property, do hereby authorize
ii n j p
of n 1 `S dUa I h� o �S4CIA,c-�� do n i�► n I'D 1 n t' � t �-CA
Name Agent Company Name (if applicable)
to act on my behalf and take all actions necessary for the application, processing, issuance and
acceptance of this permit, certification or authorization including all standard and special conditions
attached.
I hereby certify that the above information submitted on this form and application is true and accurate
to the be of my knowledge.
Authorized Agent Name / Company:
Authorized Agent Signature:
Date:
u(JI or,

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