20201016 Ver 1_Shoreline Stabilization_20200805

_:. �
;; , 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 OUALITV 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 RECEIVE D
Raleigh, NC 27699-1617 Raleigh, NC 27604
AUG 0 5 2020
A. Applicant Information [15A NCAC 02H .0502(a
1. owner Information NCDEQIDWR/NPDES
Name: �^ [ _��
Mailing Address: � 5 I�bb�i-��{„r�
S�tn►rr�. , N L �'139 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/reaulatorv/repdocs/Permits/SAMPLE AGENT AUTHORIZATION FORM.pdf)
Name: � („ 1n%� � �Cp,('S�n
Company Affiliation: /1'lo�p�c.Iu.�S� ��i0� �-' �� �a
Mailing Address: �-}� y (j �� (� T� H-wY
So wFh '8o9fon VR' o'!�( S'"12
Telephone Number: 43`� S'14 541,e' Fax Number:
E-mail Address: Joe. Q. ,rK.,pl..k.�/'�er.i-�s.� I�v�^� . c.,r-.
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: �� Nearest Town: Rox-b•r• �'N�
Lake/ river/ ocean adjacent to property: �� � �-
Property size (acres): ��,a,cr
Subdivision name or site address {include phase/lot number):
Directions to site -please include road names and numbers, landmarks, etc.:
N�- - 5'1 1 Zion l,�f.Ve,1 CM►wr�' '� � Q,;,1f w ow:l IZeorL � � q,+ o� fZc,i�f�l-�' �•I!
Latitude (in decimal degrees) 3��`�KS>s Longitude (decimal degrees) `�4 ' ��75�(r
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): ��p,srrr. �b�.hJ►+1 .i+�,r,�f.'..1 �s P rc..P u.,.t� h... Q+.d .f.D .%:lu,,�c
Q� Sh6�t �:�•{.� W�l� C'�uild � Se`mue{,,,JO �'����,J�d
7. Will work be conducted from land? �w�..� (!!From water?
8. Total amount of impacts below the normal pool lake level /Normal Water Level ' � t
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
1�0 �+ Z A. � .rctL -�.. i � I LD' 1 en w r L7 ' -fir1A
Temporary impacts in square feet:
3 � �0 �.2
9. Total amount of impacts above the normal pool lake level /Normal Water Level and 50 feet
land -ward
Permanent impacts ((i�ncluding back fill, excavation, rip rap, retaining walls, etc.) in square feet:
29 D .prL q� w� emu. � l ?.9' t aria x. �-' o.�rr�- -�R.d r oioe t
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
Owner/Agent's Signature* j15A NCAC 02H .0502(f)j 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: SSGP 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)
�o' gay
c3�..
Full Pond/ Normal Water Leve! �� .,� `���'
�����
Shoreline
�,����
� �
Plan View
FORM: SSGP 02-2017 Page 3 of 4

N
,�
Lake r� �;
(At Full Pond/ Normal Water level)
a�
c
F
°�
L
L
O
Z
O
L
to
Side View
lOf
h�
Side Vi
0
�.
Full Pond/ Normal �at�r
a � �i`hore�ne
7 h.a150 h.
addlnanal dearing
' rf necrssery
Plan View
Lake
(At Full Vond/ Normal Weler Level( Existing Dock
/30hx7h
��sa� ;�sss•
i �•
ft. additional clearing
'lf 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: 9949-ou ���t1�
STREET ADDRESS: _—_ � S _— 1��t,�p`+ '1',�''�_L.,-__—__—__---__—
�ie�-�. N � a �3U3
Please print: (',.,,, � I '��
Property Owner: _ �_— _�_ y _—__—__— _ ___
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
� %�
d Q�—N� 1���- -- --� of 'lulvar�' �1/•
(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 ail 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 Signat r Authorized Signature
Date: __� y � �_ —_ Date:

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