20200831 Ver 1_Shoreline Stabilization_20200624

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
DWA 15A NCAC 02H .0500 - Water Quality Certification, Shoreline Stabilization
Division of Water Resources 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 Et Buffer Permitting Unit t�
1617 Mail Service Center ! D
Raleigh, NC 27699-1617 J U N 2 4 2020
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information _
Name:
a
DENR -WATER RESOURCES
TRANSPORTATION PERM"NG UNIT
Mailing Address:
q3J 6 � 1 i�►�c ur
ry e- OL, sot I
Telephone Number: Z Q - ' - 754 Fax Nu ber:
E-mail Address: s s
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/reigutatory/
regdocs/Permits/SAMPLE_ AGENT_ AUTHORIZATION_FORM.pdf) must be attached if the
Agent has signed this application form.
Name: i1�1 ,
Company Affiliation: eu�
Mailing Address: v^
Telephone Number: 999-Zi4W 2PAFax Number:
E-mail Address: Mrllz:a 44A f�Jr-�Ci' .�;�`\' K.-I/YN,
Person to receive the Certification Approval: /11 ,`%%/e.
II. Project Information [15A NCAC 02H .0502(a) Ft (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, etc.), rip rap, excavation or dredging below Full Pond/
FORM: SSGP 10-2013 Page 1 of 3

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: MG. Nearest Town: ��rCIn.� e_. �CZd
Subdivision name or site address (include phase/lot tuber):
i t-, ,r__ ,a ---
Directions to site - please include road names and numbers, landmarks, etc.: _
Latitude (in decimal degrees) Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of &S
application (residential, undeveloped, etc.): �r A c�_JC_- ipe��
6. Property size (acres): U c, cr-e
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): ko; ) i2c,4--1QN,
9. Will work be conducted from land? yeJ 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 normal pool lake leevvell/l Normal Water Level
and 50 feet land -ward in square feet or acres:
12. Please describe the vegetation above the normal pool take level/ Normal Water
Level and 50 feet landward to be impacted (number of trees, for instance):
Owner/Agent's Signature" [15A NCAC 02H .0502MI Date
FORk: SSGP 10-2013 Page 2 of 3

'Agent's signature is valid only if an authorization letter from the owner is provided.
Full Pond/
!Normal Water Level
M
Shoreline
MCA
Lake
(At Full Pond/Normal Water Level)
M011 he,6o 116r1)%,, (w
Cto- Vic-'
q t abr?�- nvf Mai
Please approximately sketch the following information on this plan (provide
dimensions for each item, such as 10 ft x 100 ft)*: J
1. All proposed vegetation clearing Obi )q �e-F 44
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level
elevation Z7""
3. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level
r
elevation %(
4. Location of any proposed structures such as buildings, retaining walls, docks, etc. fi&je -
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level
elevation n 0 Ile_,-
6. Location of construction access corridors
O'AC c y-- , 5�-`rs
FORM: SSGP 10-2013 Page 3 of 3