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State of North Carolina
DWR Department of Environment and Natural Resources
Division of Water Resources
Divislon of Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
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 & Buffer Permitting Unit RECEIVED
1617 Mail Service Center
Raleigh, NC 27699-1617 O C T 2 3 2020
I. Applicant Information [15A NCAC 02H .0502(a)] NCDEQ/DWR/NPDES
1. Owner Information
Name: Kevin Keaney
Mailing Address: 2092 Riverview Road
Lexington, NC 27292
Telephone Number: 704/743-7858 Fax Number:
E-mail Address: [e-mail]
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.miI/Portals/59/docs/reizulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: N/A
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Person to receive the Certification Approval:
II. Project Information [15A NCAC 02H .0502(a) & (b)1
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. stnlrturps (hilildinPC rptninino wallc tinrkc imnoniiniic ciirfnroc
FORM: 5SGP 10-2013 Page 1 of 4

etc.), 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.)
4. Location of the property (where work is to be conducted)
County: Davidson Nearest Town: Lexington
Subdivision name or site address (include phase/lot number):
2092 Riverview Road
Directions to site - please include road names and numbers, landmarks, etc.:
1-85 to Lexington exit for NC Hwy 8, go south on NC Hwy 8, R on Linwood Southmont Rd.
L on Riverview Road, property is on the right.
Latitude (in dedmo/ degrees) 35.40.62 Longitude (decimal degrees) 80.18.28
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Single-family residential community
6. Property size (acres): 0.34 acres
7. Lake/ river/ ocean adjacent to property: High Rock Lake
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): To stabilize an eroding shoreline and protect it from
further erosion.
9. Will work be conducted from land? ® 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:
200 Sa. Ft.
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 50 feet land -ward in
square feet or acres: 750 Sq. Ft.
12. 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): 6 to 10 trees of varied
size. species and condition will to be removed to comviete the stabilization project.
9/29/2020
Owner/Agent's Signat e- 115A NCAC 02H .0502(f11 Date
`Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Lake
(At Ful PoWNormal Wafer Level)
Full Pond/
Normal Water Level
S
SEE ATTACHED SITE PLAN AND DETAILS
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft)*:
1. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
3. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
4. Location of any proposed structures such as buildings, retaining walls, docks, etc.
S. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corridors
FORM: SSGP 10-2013 Page 3 of 3

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VEGETATE DISTURBED AREA
ABOVE SLOPE
EXISTING GRADE
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EROSION CONTROL FABRIC J-4p'
LAKE BpnOM - -
TYPICAL CONDITIONS
12" TO 36" ERODED CUT
WAVE EXPOSURE
FOR: KEVIN KEANEY & DAN DeLAY
LOCATION: 2092 RIVERVIEW ROAD
RESERVOIR: HIGH ROCK LAKE
PROJECT: SHORELINE STABILIZATION PROGRAM
PHASE I SITE EVALUATION
YADKIN, INC. — BADIN, NORTH CAROLINA
DRAWING TITLE: DETAIL
MINOR RIP RAP STABILIZATION 2

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State of North Carolina
Department of Environment and Natural Resources
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Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: Kevin Keanev
Mailing Address: 2092 Riverview Road
Lexington, NC 27292
Telephone Number: 704/743-7858 Fax Number-
E-mail Address: [e-mail]
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/dots/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: N/A
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Person to receive the Certification Approval:
Fax Number:
II. Project Information [15A NCAC 02H .0502(a) & (b)l
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. strurtures lhuilHinvc ratainino walls rinrkc imnoruimic ciirfnroc
rvnrvi: aJUr tU-tins Page 1 of