20200326 Ver 1_Shoreline Stabilization_20200302

State or North Carolina
Department of Fu-uosment and Natural Resources
Division of Water Resources
ISA NCAC 02H .0500 — Water Quality Certification, Shoretlue Stabilization
FORM: SSGP02-2017
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 115A NCAC 02H .0502(a
1. Owner Information
Name: Al"I"r'l Z vol� �l
Mailing Address: �
poi li;�A /li
Telephone Number: Fax Number: r I
17may=
El.
E-mail Address:
IJ Ldrf �! �,�<� c s/Z, Cm {�151.1 @ Ss CBev,
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:
httv:/%www.saw.usace.army.mil Portals, 59,docs/regulato".Rdocs/Permits,SAb1PLE AGENT AUTHORIZA
TION FORbi.ndf)
Na�6Mt / y
Company Affiliation: t_�Nc)r� ftr_s
Mailing Address:
1t"n�o ESv % -(-E
Telephone Number: Fax Number:
E-mail Address:
S►�S �,C-i�I� O
B. Project Information 115A NCAC 02H .0502fa) & (1211
L 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.
S e- --_-� ►4'e roc- H'E`�
https://files.nc.gov/ncdeq/Water%20Quality/Surface%2OWat...0Permits/SSGP%2002-2017%20Shoreline%20Form_final.docx 2/18/20, 2:35 PM
Page 1 of 5

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.
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: Pco Nearest Town:
Lake/ river/ ocean adjacent to property: 1. /=-K4E- /J O V,�.-(M torf-3
Property size (acres):
O , -7 1 �S
Subdivision name or site address (include phase/lot number): W E�5-rPb PT
(JE�Ot,O ( Ne-- dl�-OS-7 Lzrr*ta7
Directions to site - please include road names and numbers, landmarks, etc.:
i f (. - -15 t,, /5A-?n V U- . cZ� In , S fr : XeS
F'`(, w-7- 6 0 C-(-� e 0 e- - a . `( m
KA CM WI— o r') N \'Ica tj M-S I (!,�t"� O. 1 IY t
Latitude (in decimal degrees) -
degrees, 35 ,5a-7 5 3o
Longitude (decimal
PE►J I N S L& --A
5. Describe the existing land use or condition of the site at the time of this application (residential,
undeveloped, etc.): ` CJiS 1
6. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary): l.Xs) C' R ` P (z ." D
ILZ N 5�i3) L-- z�-t p� 1� 1'� i
r�t� �a�� poN� i� c� ��� UPS/NG I.-on�� (Z� ►��t�' `�
7. Will work be conducted from land? From water? V
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
16u sCI
Temporary impacts 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:
https://files.ne.gov/ncdeq/Water%200uality/Surface%20Wat...0Permits/SSGP%2002-2017%20Shoreline%20Form_final.docx 2/18/20, 2:35 PM
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Temporary impacts (temporary clearing, construction corridor) in square feet:
�-)1!ns\
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):
11. signature
Owner/Agents Signature' [15A NCAC 02H .0502(f)] Date /p� I /
Agent's signature is valid only if an authorization letter 111
from the owner is provided.
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
take
e J, (pt Frill Pond/ Normal Water Level)
Full Pond/ a �.y��i ttrl ataa aa.... ■
5
R t P (�-P
Plan View�--
1 C,
https://Iiles.nc.gov/ncdeq/Water%2OQuality/Surface%2OWat...OPermits/SSGP%2002-2017%2OShoreline%20Form_final.docx 2/18/20, 2:35 PM
Page 3 of 5

Lake
wren mN«am. rime V eq Existing Dock
/ lQka)k
��.r�1�1111111, � r
E AMPLE
Plan View f
�..._....�......_v.v ..lake �._.....w.__..�.rt.a..�. �.�
j (At Full Pond/ Normal Water Level) 3
I C
E d
`' O
Z i
C
O
Side ViewCL
LL-
3 ft, below full pond water level 4 ft. above fuH pond crater level 2 ft. additional Bearing
'if necessary
Existing bank
10 ft. bank
height
Side Vi -7
https://files.nc.gov/nccieq/Water%20Quality/Surface%2OWat...OPermits/SSGP%2002-2017%20Shoreline%20Form_final.docx 2/18/20, 2 35 PM
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