20200309 Ver 1_Shoreline Stabilization_20200226

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent.,I
to: I�
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
1. Applicant Information 1`15A NCAC 02H .0502(a)]
1. Owner Information _
Name: pd}/J i'�L j S.
Mailing Address: K' 0 _ � & }C _F T %
Telephone Number: 77 21 Fax Number:
E-mail Address:
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http://www saw usace army mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: � r' �Ar
Company Affiliation:
Mailing Address:
Telephone Number: 2 F_.Z� �y7 Fax Number: 8�& - 7y'Z -4 2 C'
E-mail Address: C'__ o _!�; (Lb� C_A_ 1 C'v
Person to receive the Ce ific ti n Approval: Zo 77
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.
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: 4;7l'-wSot� Nearest Town: CoccbX3 f,E:,az C►1, V1��
Subdivision name or site address (include phase/lot number): S/�o�c,� .s?.�3�i✓�S�aN
11711 �Js�6✓� 1S2�rr� C���� N� 28723 , Lr¢k� �
Directions to site - please include road names and numbers, landmarks, etc.:
Sl�lil s Ta �L y0 /10a1:'62 2P o/U 019r ILIA« To
1>KI04r, oN RAWT 7-0 117y O/v
Latitude (in decimal degrees) 3J� 1721 7_/ Longitude (decimal degrees) —±3 , /53
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): ,410
6. Property size (acres): J t)-CYL'_F f-
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): %o/ji�iG> Z� S/YdE'���N i S�4)
�y2TTf p2 fr.Ac10 S /IJ11)
9. Will work be conducted from land? ❑ From water?
10. 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:
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the norm pool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres:
.S 0
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): �/�✓�- !�o t��
dZ-ze,-ZZ)
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 10-2013 Page 2 of 3

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