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Home My WebLink About20200298 Ver 1_Shoreline Stabilization_20200225State of North Carolina Department of Environment and Natural Resources Division of Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization tr FORM: SSGP 02-2017 Io0s 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, 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 [15A NCAC 02H .0502(a)] 1. Owner Information -� Name: `1 1I6_1" �_C_-- Mailing Address: ��, 1 %�r ('-( L I4NJ/`(_1•1 ( 2 1Z,/7) tA) C_ Telephone Number: �'C y - _4L/ Fax Number: E-mail Address: �LI I ��%a IL: ��/�:`Z �� % p0 ►/4 t L • �'vt 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: ,)ttp://,ijw ., sav--r <«ac= arrr,y mil/Po,-aisJ-9/dots/reF-ulatori/,,eRdocs/Permits/SAMPLE AGENT AUTHORIZ ATION FORM.pdf) Name: Company Affiliation: Mailing Address: Telephone Number: E-mail Address. Fax Number: B. Project Information f1 5A 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 photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale of some sort- a yard stick, shovel handle, etc.) 4. Location olthe property (where work is to be conducted) I , County: f �,ti (?� �J�-f �;2- ( Nearest Town: i"1 ( �, �� ✓k Lake/ river/ ocean adjacent to property: l�-t t L� l� l L �✓ZY Property size (acres): U I ' A C4tj_ Subdivision name or site address (include phase/lot number): 11(_E Directions to site - please Include road names and numbers, landmarks, etc.: 5�L )CA rv'-) de (in decimal degreesjZ,L, E, - c- Longitude (decimal degrees) 1 ��1 65� '60 S. Describe the existing land use or condition of the site at the time of this application (residential, undeveloped, etc.): /� < < % 1 ►,) �- 6. Describe proposed work (include discussion as to how hardening of me has been avoided, or why it is necessary): 5) +L � _ i , N' . 5 +)q � , i 2-/4 -7) G 7. Will work be conducted from land? a_� From water? ❑ 8. Total amount of impacts below the normal pool lake level / Normal Water Level Permanent impacts (including all excayption, backfill, rip rap, retaining walls, etc.) in square feet: Temporary impacts square feet: 9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet land -ward impacts (including back ft excavation, rip rap, retaining walls, etc.) in square feet: Temporary impacts,(temporary clearing, construction corridor) in square feet: 10. Please describe the vegetation above the normal pool lake level/ Normal:�ter 1p and 50 feet landward to be impacted (number of trees, for instance): 11. Signature CIE)/I�U 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 02-2017 Page 2 of 4 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 Full Pond/ Normal Water s = Shoreline Plan View FORM: SSGP 02-2017 Lake (At Full Pond/ Normal Water Level) Lake Iu Fun PmW No rwd Vft tVKq Existing Dock 3Uft. 7h 3 ha M1, aebn Gi paty NWL Full Pond/ Normal Water U_vel WAW�-� shoriAJ Fdprap*Apowfm addliorol ckering--Cr • If rctecsary p,g ,¢wE7(AMPI�E Page 3 of 4 a Lake 0�1 (At FuU Pond/ Normal Water S I E a �0 Z� Side View 2 ft. additional clearing 3 ft below full pond water level 4 ft above full pond water level *If necessary Existing bank 10 ft. bank ISide Vi AMPLE FORM: SSGP 02-2017 Page 4 of 4 r N. dOWL IOQ L 1r P." a r.r .r M .6►. 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