20201015 Ver 1_Shoreline Stabilization_20200805

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t �(�- State of North Carolina
Department of Environment and Natural Resources
,. � Division of Water Resources
Water Resources 15A NCAC 02H .0500 —Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL QUALITY 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 Brar�q E C E I V E D
1617 Mail Service Center 512 N. Salisbury Street j"'(
Raleigh, NC 27699-1617 Raleigh, NC 27604
AUK 0 5 2020
A. Applicant Information [15A NCAC 02H .0502(a)� NCDEQIDWRINPDES
1. Owner Information
Name: � � � �f7�t'n
Mailing Address: '1 y �bb��- ��V+
Se,�v►�r� ,N L 1734 3
Telephone Number: Fax Number:
E-mail Address:
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://www.saw.usace.army.
mil/Portals/59/docs/requlatorv/regdocs/Permits/SAMPLE AGENT AUTHORIZATION__FORM.pdf)
Name: �C M(� i�GP,C3�n
Company Affiliation: mapk�u.�s� o��� �-'�'��
Mailing Address: �{t y (i �� [� -t�� E.f.,vY
SO WF}� '8a9fOn V� aY b'"12
Telephone Number: 43� S't4 SGI,:' Fax Number:
E-mail Address: Joe. Q ar�..pf�1�'sFe�i'Js,< I�v��y , cer-.
B. 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, 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.)
FORM: SSGP 02-2017 Page 1 of 3

4. Location of the property (where work is to be conducted)
County: •,G�Wty1 Nearest Town: Rsx-�vr• �'N�
Lake/ river/ ocean adjacent to property: I�c� Lfl �-
Propertysize (acres): i�,�,�
Subdivision name or site address (include phase/lot number):
"'�y��.bbs�- Ike 1..�► Scr�� nk. ��3y3
Directions to site -please include road names and numbers, landmarks, etc.:
N� - 5'1 � ?.ion livc 1 Ctiw� �� Q;�r� �+^ ow:l Z.o+� � � �.+ a R�,6641-I� ir1
Latitude (in decimal degrees)
Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application (residential
undeveloped, etc.): �`��
6. Describe proposed work (include discussion as to how hardening of shoreline has been avoided
or why it is necessary): �'��i/�.-b�,F►�.d .i+�,�►'••1 �� P rc•P � h•.• Qsd .f"D f+►.'lu,..c
o� share I;�.� w�U rebw�d 1.,() SeJ�.,la i�.'���w�.�l
7. Will work be conducted from land? �� From water?
8. Total amount of impacts below the normal pool lake level /Normal Water Level ' j f
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
iL0 �t� A' �.rtl1 �x�• �' �di leinw v i � -firL
Temporary impacts in square feet:
� 3 0 00 �.2
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:
�� � �PtL d �.ra� �,.. '�. 1� �� l av�,� x. �-� el�rc..� „1 r oe.1
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 impacted (number of trees, for instance):
11. Signatur
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Owner/Agent's Signature* (15A NCAC 02H .0502(f)1 Date
*Agent's signature is valid only if an authorization letter from the owner is provided.
12. Please approximately sketch the following information on this plan and provide dimensions for
each item:
FORM: 5SGP 02-2017 Page 2 of 4

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
Lake
(At Full Pond/ Normal Water Level)
Full Pond/
�.
Plan
FORM: SSGP 02-2017 Page 3 of 4

c
Side View
Full Pond/ Normal Water
� �i`horeTne
2 h.z150 h.
addlUonal dewing
' if necessary
10f
h�
Plan View
Side Vi
Lake
(At Full Pond/ Normal Water Levey Existing Dock
/30hz7h
'v�rvv=irw ..►
�i;:�ic �� y'i'�i —
,�r, ,��i,1 iltiy�
� .L�r
•
ft. additional clearing
"if necessary
FORM: SSGP 02-2017 Page 4 of 4

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SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT N0.
PLAN N0. PARCEL ID: 9g49-vy �����•�
STREET ADDRESS: � � �^��17'+ ' ^' L-h
���. N � a �343
Please print: �/ �/��
Property Owner: _—_ _—__—_-- _
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
a ,���a� D�,dblar�- .�v
—_, of --- ---
(Contractor /Agent) (Nam of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
Telephone:
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signatupg � Authorized Signature
Date: _ � �% � _��__—__�w Date: