20200350 Ver 1_Shoreline Stabilization_20200305

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State of North Carolina
Deparhaent of F.arunument. and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 - Water Quality Cerdfleation, Shorelute Stabiruation
FORM: SSGP 02-2017
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 [ 15A NCAC 02H .0502(a)J
Owner Information
Name: (r � C l7-� A C (_ '�— ZC F'M f-V tJ
Mailing Address:
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Telephone Number: Fax Number:
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E-mail Address:
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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:
http://wwryv.saw.usace.armv.mil/Portals/59idocs/regulatory/regdocs/Permits/SAMPLE AGENT AUTHORIZA
TION FORM.pdf
Name:
Company Affiliation:Owe- V-X
Mailing Address:
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Telephone Number: Fax Number:
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E-mail Address:
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B. Project Information l l5A�NCAC 02H .0502(a)& hA
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. /
https://Files.nc.gov/ncdeq/Water`/20Quality/Surface%2OWat...OPerniits/SSGP%2002-2017°/*2OShoreline/o2OForm_final.docx 2/18120, 2:35 PM
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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.
'SE-E, qc'i T `T-lel�ty�
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: Nearest Town: `
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Lake/ river/ ocean adjacent to property: /J bQ (�f1 ►�
Property size (acres):
1 i 91 6 PC(:cS
Subdivision name or site address (include phase/lot number).
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Directions to site - please include road names and numbers, landmarks, etc.:
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P1 C, aa-T 1713-7f-D L37 C7,3% c3S 'P- �!-b • O • U rim L-e S
lam ' 0 PJ C 1 a� �� L N n, i fil L C� vow L L)e6b C-" i �L 0 . `7 e " l_5
Latitude (in decimal degrees)- Longitude (decimal 1 °� t�-� '5 /J
aa � . � iiY\ i `QS
degrees) J� . 5aq O2.e c'� _ g l uc�� 130
5. Describe the existing land use or condition of the site at the time of this application (residential,
undeveloped, etc.): r�__ �_ f ec)1 i Y=Y l'
6. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
Ay it is necessary): S�l� �� Zf�� ukS / fi
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7. Will work be conducted from land? From water?
S. 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:
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:
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Temporary impacts (temporary clearing, construction corridor) in square feet:
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50 feet
landward to be impacteZ(nber of trees, for instance): _
A)b 20E/
11. Signature
Owner/Agent's Signatuk;415A NCAC 02H .05021] Date
Agent's signature is valid only if an authorization letter
from the owner is provided.
https://files.nc.gov/ncdeq/Water%200uality/Surfacel2OWat...0Perniits/SSGP%2002-2017%20Shoreline%20Form_final.doex 2/18/20, 2:35 PM
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Side View
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3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additions! Bearing
`tf necessary
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Side Vi
https://files.ne.gov/ncdeq/Water'/200uality/Surface/2OWat....0Peri-tits/SSGP%2002-2017962®Shoreline%2OForm-finai.docx 2/18/20, 2:35 PM
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