20200432 Ver 1_Shoreline Stabilization_20200327

State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
Division of lh'ater 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
to:
Division of Water Resources
401 & Buffer Permitting Unit 0
1617 Mail Service Center D
MAR 2 7 2020
Raleigh, NC 27699-1617
DENR -WATER RESOURCES
TRANSPORTATION PERMITTING UNIT
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: 111:n nlr,c� �lc��$r�l�e-Ic�Ii1�Q�T
Mailing Address:
IS
Telephone Number: —?CS �- pZ0 )- I �'�� Fax Number: AL%Ae-
E-mail Address: S4 Lk�, res $ VD V ' 6t) t-4
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/dots/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: Jac �.-;-T 0V;5 Gbr40Z_+ xa--n
Company Affiliation: W t i A ckhJ kvtx,*P,!
Mailing Address: FCS 9, "4 36."
7� f re,i i , Nc,
h
Telephone Number: 7c�-J-A,2,1 Fax Number: 6h-e,�
E-mail Address: �)lc*���>
Person to receive the Certification Approval: v 19
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: 177a<k/er, b"r. Nearest Town: 6" csxl7dW
Subdivision name or site address (include phase/lot number): 67I6A5 AiV Erb Dl'W (0177?li hf
L err `/ 7
Directions to site - please include road names and numbers, landmarks, etc.:
rr&0) 64a.r14 e, ' --1:- 7i 1Wr-� -4p O."I'DE 4d t 6 -
6vr+b C cA4,tW �?,k f-lup . K, 4 lit- esli 7a l J nce— C 4 a fl t 1 Ar4 . Lts(-k-6 w
C&(-,,d& DcUQ-_ ZeR�ci4 L4it ors IJcu�
Latitude (in decimal degrees) LI `/ 735, !�;? Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): k5"Jer.4"A\
6. Property size (acres): 0, 9 3 ) cy-
7. Lake/ river/ ocean adjacent to property: sake_ tyi)(1i 44
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): rT p s,Ar feb'AQ 54476, ` ; ZIA+iM
` ZN Q�10 e rQ`ro n
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:
r%n - fib aaJJrwA, 30P Sov-
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres: VQ -
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):
A&nP, 4-z> Ho_ "101Dar.IJ & QAISoe. r)h-r
Owner/Agent's Signature
Printed Name
1`15A NCAC 02H .0502(f)l
'Agent's signature is valid only if an authorization letter from the owner is provided.
Date
FORM: SSGP 10-2013 Page 2 of 3

V
NMI
INoirmra.all'Wateir Lovell
Shoreline
E
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v
i4W lke
(At Full Pond/ NowvA Water LeM)
r; p -tip -1 cs 5��
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7q, I -FeeA-N!!� 66 ova
aha K' below -Tao r-K
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Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft)*:
1. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
3. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
4. Location of any proposed structures such as buildings, retaining walls, docks, etc.
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corridors
FORM: SSGP 10-2013
Page 3 of 3

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map or report prepared for t • Inventory of real property within Mecklenburg County an oom m noo ah, tax maps, away&, planimeft maps, and other public records and data:
Users of this map or report am hereby notftd that the aforementioned public primary Information sources should be consulted forvedlation, Mecklenburg County and its mapping contactors assume no legal
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