20211753 Ver 1_Sketch_20211205

PROPERTY LEGAL D€SCRIPTION:
LOT NO: .5 1/ PLAN NO:
STREET ADDRESS:
Please print:
Property Owner: 0 Fury �i e- S Lcy
Property Owner:
PARCEL ID: 217- 6Y -j--G
The undersigned, registered property owners of the above noted property, do herebyauthorize
Randall Clawson
of Clawsons Pile Driving and
Construction
(Contractor/Agent)
(Name 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 Owners Address (if different than property above):
Telephone: ���� (� �% ✓ �!o s�
We hereby certify the above information submitted in this application is true and accurate tothe
best of our knowledge,
Authorized Signat
12-1-202-1
Date
Authorized Signature
Date

CATAWBA RIPARIAN BUFFER NOTIFICATION FORM
Project Name/address: /S,3�� County:
Owner:
Contract
rnnt J1511CI LUI Q
The approval is for the purpose and design described in your application. Impacts not indicated in the
application is a violation of the Buffer Rule. Site specific work should be provided in the application. [15A NCAC
02H .0506 and 15A NCAC 02B .0243(8)]
Trees are not allowed to be removed from Zone 1 of the Buffer (within 30 ft of the full pond elevation), unless
approved. Exception, those trees that are severely undermined along the immediate shoreline can be removed.
Minimal shaping and sloping along the immediate shoreline is allowed. [15A NCAC 02B .0243(6)]
Benching and grading in the buffer is not allowed. Excessive disturbance of ground cover. [15A NCAC 02B .0243
(6)]
Beaches, impervious patios, impervious walkways, etc. are not allowed in the buffer unless specifically approved
by the Division. There are limitation on size for decks. [15A NCAC 02B .0243(4) and (6)]
Work to be conducted from land must indicate an access and indicate any trees that are to be removed. The
work corridor should be described. The approved access corridor shall be restored. Staging, spoil, construction
material must be outside the buffer. [15A NCAC 02H .0502 and 15A NCAC 02B .0243 (4), (6), (8)]
Stormwater cannot be piped or channeled for direct discharge to the lake. All constructed stormwater
discharges must be at the natural elevation and discharged prior to entering the buffer directed as diffuse or
sheet flow at non -erosive velocities to the lake. [15A NCAC 02B .0243(5), (6)]
Acknowledgement of Notification
I, L. 0: 'Z tZ`t L m-:r , hereby state that I have been informed of the Catawba
Riparian Buffer Rule. Any work conducted in the buffer, not specifically stated in the application and approved
by the Division of Water Resources (DWR), is a violation and subject to enforcement. Due diligence will be
taken such that the construction will be built within substantial compliance and intent of the 401 Water
Quality Certification and Buffer Rules, the approved plan(s) and specification(s), and other supporting
materials.
Signature (owner): �r� �--.� Date: