20200461 Ver 1_Shoreline Stabilization_20200402

State of North Carolina
tlepartinent of Environment and Natural #IesaUxces
Division of Water ilesooftes
Division of Warier Resources 15A NCAC 02M .0500 —Water Clualrty Certifia:atltan, Shoreline StabiliZatioat
l:f,>i M., 5SGP 10-2013
Shoreline Stabilization Application Form
Four copies of the application (including attachments) and the application fee should he sent to;
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
1. Applicant Information
1. Owner Informatinn
Name: _4 , kc. :k
Mailing
Address-2 6L
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Telephone Number: Fax Number:
E-mail Address: Q- Ack V'A /'q 5-3 ctl7CLI CcT"
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a farm can be downloaded here:
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CRIZA—P N_EQ��) must a ?t ached if the Agent has signed this application form.
Marne:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address,
Person to receive the Certification Approval:
Fax Number:
IL Project Infarmation - ',ICAr . Arc_, 1= St �„��
L Attach a vicinity snap (i.e. street map) clearly sho ing the location of the property with
respect to local Ian dmarks such as towns, rivers, and roads.
2. Provide a detailed site playa showing property boundaries and proposed locations of
vegetation clearing, structures (buildings, retaining walls, docks, impervious surfaces,
FORM: SSGP 3.0-2013 Page 1 of 4

etc.), rip rap, excavation or dredging below full Pend/ 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_ %: C Nearest Town:y,y\N
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5.
7_
Subdivision name ror site address (include phase/lot number):
Directions to site -please include road d names and numbers, landmarks, etc.: C1 _ 9
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Describe the existing land use or condition of the site at the tirrie of this application
(residential, undeveloped, etc.): Id "'Al
Property size (tiCres): as 4 C C•.2 S
Lake/ river/ ocean adjacent to property: Z a -A2
S. describe proposed work (include discussion as to how ardening of shoreline has
avoided, or why.it is necessary); pick C
9. Will work be conducted from land? yx 5 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:
G> S� r : k. In l C_ V-e l*
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 So feet land -yard In
square feet or acres: ^ --
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level a d
50 feet landward to be impacted (number of trees, for instance)6 C
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Owner gents Signature' 1`1 �3' 1 i -F -13 bate
Agent's signature is valid only if an authorization ietter from the owner is provided.
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FORM: SSGP 10-2013 Page 2 of 3
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3012-E South Elm St
KAMAN Greensboro, NC 27406
[phone] Phone [phone] Fax
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Please approximately sketch the follming informtion on this plan -5
(please pr6vId6 difiletisibnt for each �te?m, suich as 10 ft. X IOD fQ-
J) All proposed vegetation clearing (proVide dimensions
.2) Location of rip rap orfill toire placed above the Frill Pond elevation
3) Location of rip rap or fill to be placed below the Full Pond elevation
4) The toe ation of any proposed structures such as buildings, retaining
walls. docks, etc-
s) 111c location of any excavadon or drWgiiig below the Full Pond
elevation.
6) LocAtion of congtrutticn access corridors.

Kaman Industrial Technologies
KAMAN
3012-E South Elm St.
Greensboro, NC 27406
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Kaman Industrial Technologies
KAMAN3012-E
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Greensboro, NC 27406
[phone] Phone [phone] Fax
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