20200286 Ver 1_Shoreline Stabilization_20200220

State of North Carolina
�:- Department of Environment and Natural Resources
Division of Water Resources
iSA NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 02-2017
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the should be sent to:
If sending via US Postal Service If sending via delivery service (UPS, FedEx, etc.)
Karen Higgins Karen Higgins
DWR - 401 & Buffer Permitting Branch DWR - 401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information [
1. Owner Information
Name:
Mailing Ad
Telephone Number:
E-mail Address:
tea, �':..` t r�r`L� I)Y
704-275-4108 Fax Number:
[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:
htto://www.saw.usace.armv.mil/Portals/59/docs/,-eaulatorv%regdocs%Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf) A /
Name: Mal -A"
Company Affiliation:
Mailing Address: S C 7 Hc.--holr Ad, Mcwtvood Al C
2 ff/Z V
Telephone Number: Toy 985 6 rS 2 Fax Number:
E-mail Address: /7a �i r,.�ca++s�rL-e-l' 6- to-o r+--4L►'11 coo —X
B. Project Information [ - -
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 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: 6-A Nearest Town: �" OJ �'Oo7 a
Lake/ river/ ocean a jacent to property: ^ v
Property size (acres): a S
Subdivision name or site address (include phase/lot number): JCS l,Y Y
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (in decimal degrees) 3 Si 22 Pno Longitude (decimal degrees)' F , O 72 �/ 0
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): rCA /iGl.,/
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): rluae c GeV^GrtA-c 6/e c, k cvc, // im i��
r; j2-rc-A
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 (includinf
� x Sao fel�.l
Temporary impacts in square
r.
all excavation, backfill, 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
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
SX/C3G / 0Y4Q. / SOO sgaf
Temporary impacts (temporary clearing, construction corridor) in square feet:
/o X xxi- I 40v a s9 -
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): rCPHVk,{ 2 dry -'CS
�y 5 ,ory�nt
11. Signat
Owner/Agent's ignature* [15A-Date
`Agent's signature is valid only if on authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 of 4

11. sign ze
Owner/Agents Signature (15A NCAC 02H .0502(ol Date a /z $' / ! C(
Agent's signature is valid only if an authorization letter
_ from the owner is provided
12. Please approximately sketch the following information on this plan and prmw,. dons for
emk 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 nap or fill to be placed below the Full Pond/ Normal water level elevation
d. Location of any proposed shuctmw such as buildings, retaining was, docks, eta.
e. Location of any excavation or dredging below the Full Pond/ Normal water Level elevation
Lake
(At Rdl Pons/ rdormal water Level►
Full Pond/ Normal Water Leven a Q C> 1
Shoreline � ��U�Cj p O � �
o
yap\ �'� 60�
06
Plan View
3R.IUA
Ffi IO01
lR.=k
airla�dn t
•r.san�
FXAM
Plan View I

Side View
3 ft. bebw fug pond water level 4 ft. above fuk pond water *W 2 ft. addWo" ckarbg
i 1 •if n"ft-. y ■
—j
FORM: SSGP 02 2017 Pale I of 3

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 5`7 — PLAN NO.
STREET ADDRESS: 55 /j'
Please print: c
Property Owner: J eay1 Cr'
Property Owner:
PARCEL ID: a ca 73 5
The undersigned, registered property owners of the above noted Property, do hereby authorize
AlaAcx.n Alp" &"A^, al , of Al A -
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance 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):
9a-3- Wi►�rvw
Telephoner `" a
0
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
i
Authorized Signature
Date: 16!iga 411lq
Authors re
Date: g2,,�J

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