20201064 Ver 1_Shoreline Stabilization_20200819

a
ti State o 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, Fed Ex, etc.)
Karen Higgins Karen Higgins
DWR-401 & Buffer Permitting Branch DWR-401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information [15A NCAC 02H .0502(a)1
1. Owner Information
Name: ,r.6a,e V Tq mmv
Mailing Address: 1-711 13{tilsC Danis( 90(
Telephone Number: 334 S03-7My Fax Number: V-59S-5.2 gs
E-mail Address: cel da&A s o • �o
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/reeulatory/regdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
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.
FORM: SSGP 02-2017 Page 1 of 3

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) L
County: _ Nearest Town: Qv X } *--o
Lake/ river/ ocean adjacent to property: 14.. C n. Lia k e
Property size (acres): J .0 Etc re 1
Subdivision name or site address (include phase/lot number): llaq' Co bbs
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (in decimal degrees),
Longitude (decimal degrees)
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): 2041 d0A �)fk 1 J0.i4;Q , Cko e d W044 4%0tway
6. Describe proposed work (include discussion as to how hardening of shoreline has bean
avoided or why it is necessarryy)� -T^skl I 't-roc' � d W0&d SkW W a Il &V ; tl+ 0,0 p ro?
sej� A d wR 11 +0 sfe? f4 ee05;D'►
7. Will work be conducted from land? Ni---" From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
sll 6qa
Temporary impacts in square feet:
102 n
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:
1 360
Temporary impacts (temporary clearing, construction corridor) in square feet:
110'T O
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50
feet landyjard to be impacted (number of trees, for instance):
FORM: SSGP 02-2017
Page 2 of 5

11. Signature
` $-/.-boa. a
Owner/Age 's Signature` [15A NCAC 02H .0502(f)l 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:
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
a
ull Pond/ Normal Water
Shoreline
44A+;. ✓
C(er•sVf
Plan View
Lake
(At Full Pond/ Normal Water Level)
Hof
Docy-
0- pop
OCCaoi.O C; (
R P RAP
a
3' LiyA+- lAn eLlyiocvti,
a'x 340`
3' Jr 3�ic�
FORM: SSGP 02-2017 Page 3 of 5

P + WIC
PC p"A 1
-9"MMP
Lake
(At Full Pond/ Normal Water Level)
Side View
Full Pond/ Normal Water Le
n4morefine � w
2ft..150h-
Plan View
3Ft-dirj*Q,C F(AI% 1/001
.14
W
Lake
(ft RA P.W Ij­, Existing Dock
,/ 30 ft. 7:,
R,prap Abm f0i W-V UM
D I
ri TuTeu I
FORM: SSGP 02-2017 Page 4 of 5

3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
'if necessary
Existing bank
10 ft. bank
Side Vi
FORM: SSGP 02-2017
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Page 5 of 5

ArcGIS WebMap 1 a 9 Co 6-s b e-r k Izel-
1:4,bI4
6/15/2020, 4:15:18 PM
0 0.03 0.06 0.12 mi
Addresses Parcels 2017 Aerial Photo Green: Band-2
0 0.05 0.1 0.2 km
Easements Roads Red: Band-1 Blue: Band 3®OpenStrestMap(and)contributors, CC -BY -SA
NOT A LEGAL DOCUMENT
Map data Q OpenstreetNiap contributors, CC -BY -SA I The Data Conversion Group of the North Carolina Department of Transportation GIB Unit serves as the date steward of this spatial polygon data, on behalf of the Powell BIII Office of the North Carolina Department

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U.S. Army Corps of Engineers (USACE)
Form Approved -
APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT
OMB No. 0710-0003
33 CFR 325. The proponent agency is CECW-CO-R.
Expires: 01-08-2018
The public reporting burden for this collection of information, OMB Control Number 0710-0003, is estimated to average 11 hours per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services,
at whs me-alex esd [e-mail]. Respondents should be aware that notwithstanding any other provision of law, no person shall
be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT
RETURN YOUR APPLICATION TO THE ABOVE EMAIL.
PRIVACY ACT STATEMENT
Authorities: Rivers and Harbors Act, Section 10, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; Marine Protection, Research, and Sanctuaries Act,
Section 103, 33 USC 1413; Regulatory Programs of the Corps of Engineers; Final Rule 33 CFR 320-332. Principal Purpose: Information provided on this form
will be used in evaluating the application for a permit. Routine Uses: This information may be shared with the Department of Justice and other federal, state, and
local government agencies, and the public and may be made available as part of a public notice as required by Federal law. Submission of requested information
is voluntary, however, if information is not provided the permit application cannot be evaluated nor can a permit be issued. One set of original drawings or good
reproducible copies which show the location and character of the proposed activity must be attached to this application (see sample drawings and/or instructions)
and be submitted to the District Engineer having jurisdiction over the location of the proposed activity. An application that is not completed in full will be returned.
System of Record Notice (SORN). The information received is entered into our permit tracking database and a SORN has been completed (SORN #A1145b)
and may be accessed at the following website: http://dpcld defense oov/Privacy/SORNsindex/DOD-wide-SORN-Article-View/Article/570115/a1145b-ce.aSPx
(ITEMS 1 THRU 4 TO BE FILLED BY THE CORPS)
1. APPLICATION NO.
2. FIELD OFFICE CODE
3. DATE RECEIVED
4. DATE APPLICATION COMPLETE
(ITEMS BELOW TO BE FILLED BY APPLICANT)
5. APPLICANT'S NAME
8. AUTHORIZED AGENT'S NAME AND TITLE (agent is not required)
First - Co rt y Middle- E dwa l J Last- Da V j 3
First -Cott y Middle -c4wpi I Last - DDy v j S-
Company- Corey Ravi-S C0AS4VVCP*-
Company- CorrD40%S CehS%r.C7�a'>
E-mail Address - Corey e df%u7 S @ Corn
E-mail Address - 00arey C dog S ® /1�r„ • C.d r+s
6. APPLICANT'S ADDRESS:
9. AGENT'S ADDRESS:
Address- 7i( I esi, e 106;,rl Q d
/
Address- I)1( j;rff; a Db s i e If I
City - key. bra State - 4 C Zip-;L-)%j71/ Country - }�qsy,
City - Bo X bbro State - r1 C Zip-:2757qCountry /ds+
7. APPLICANT'S PHONE NOs. w/AREA CODE
10. AGENTS PHONE NOs. w/AREA CODE
a. Residence b. Business c. Fax
a. Residence b. Business c. Fax
-5 -QLf 13 L -fa- 73ait 06 sS 6,12
Q 5 &Z a SPI-6.2
.174
STATEMENT OF AUTHORIZATION
11. 1 hereby authorize, to act in my behalf as my agent in the processing of this application and to furnish, upon request,
supplemental information in support of this permit application.
43-
SIGNATURI OF APPLICANT DATE
NAME, LOCATION, AND DESCRIPTION OF PROJECT OR ACTIVITY
12. PROJECT NAME OR TITLE (see instructions)
D +_
13. NAME OF WATERBODY, IF KNOWN (if applicable)
14. PROJECT STREET tADDRESS (if applicable)
G L v, k ,t
Address 9 CObI'j creek
City - Lc as� / State- n C_zip-
y
15. LOCATION OF PROJECT
-7`1
Latitude: -N 36• q6J Longitude: oW • • ► oZ C 9 8
16. OTHER LOCATION DESCRIPTIONS, IF KNOWN (see instructions)
State Tax Parcel ID Municipality
I Section - Township - Range -
rvrcIrr 404J, MA T LU71$ PREVIOUS EDITIONS ARE OBSOLETE.

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2A. Is Any Portion of the Work Already Complete? Yes o IF YES, DESCRIBE THE COMPLETED WORK
25. Addresses of Adjoining Property Owners, Lessees, Etc., Whose Property Adjoins the Waterbody (it more than can be entered here, please attach a supplemental list).
a. Address- I;X,j C p bbS C--t-C%c �Q J
City - Le y S bW -- Q State- N . C - Zip - A i;'Q
b.Address- 1310 Cobbs [rmrek 9 J
City - Ltq S b r G State - Y1 C. Zip - a7 �1q
c. Address- J
City - State - Zip -
d. Address -
City - State - Zip -
e. Address -
City - State - Zip -
26. List of Other Certificates or Approvals/Denials received from other Federal, State, or Local Agencies for Work Described in This Application.
AGENCY TYPE APPROVAL` IDENTIFICATION DATE APPLIED DATE APPROVED DATE DENIED
NUMBER
" Would include but is not restricted to zoning, building, and flood plain permits
27. Application is hereby made for permit or permits to authorize the work described in this application. 1 certify that this information in this application is
complete and accurate. I further certify that 1 possess the authority to undertake the work described herein or am acting as the duly authorized agent of the
applicant.
%1 SIGNATURE F DoaA — -T- )2- 2D2o an=, - D -
APPLICANT DATE SIG TURE OF AGENT DATE
The Application must be signed by the person who desires to undertake the proposed activity (applicant) or it may be signed by a duly
authorized agent if the statement in block 11 has been filled out and signed.
18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of the United States
knowingly and willfully falsifies, conceals, or covers up any trick, scheme, or disguises a material fact or makes any false, ficfitious or fraudulent
statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious or fraudulent
statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both.
E,VG FORM 4344y VA Y2Of8
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