20140088 Ver 1_Shoreline Stabilization_20140127

State of North Carolina
DWR Department of Environment and Natural Resources
Division of Water Resources
Division of Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10 -2013
Shoreline Stabilization Application Form
Four copies of the application (including attachments) and the application fee should be sent to:
Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: h , lie, iV z / L 4 � G.�' . L . LLI r % r 17
Mailing Address: / ©1 020 / /,,�,,, �� �� A.
.4� t- >C /, 2 5 y Z-
Telephone Number: 'M3- 72--7- e76 Fax Number:
E -mail Address:
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 /docs /reRulatory /reRdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: . ^i,.9 T 'D : c /4'.? I
Company Affiliation: D; Lk1,',s�;11- Li-C;
Mailing Address: `2 �7j 3 'Z YFo lr- L ,,k ` ,f7.^ . ' )
yli t3 /c.0 /�:J ej � , Z'9' �} � /
Telephone Number: ef / 47— 6(J6 9/ 73 Fax Number:
E -mail Address: _ D ;i keNs�6 L, "Ji P 6 M'4 d d C.0m
Person to receive the Certification Approval: CI-1 i LJ ; CA A-7 s
11. Project Information [15A NCAC 02H .0502(a) & (b)]
1. Attach a vicinity map (i.e. street map) clearly showing the location of the p op�rtyt / w' th
respect to local landmarks such as towns, rivers, and roads. I -i/ Y.
tl
2. Provide a detailed site plan showing property boundaries and proposed
vegetation clearing, structures (buildings, retaining walls, docks, impervious surfaces;
FORM: SSGP 10 -2013 Page 1 of 4

V1.
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: n k- If -1 Nearest Town: 16 c1 ti ,
Subdivision name or site /address (include phase /lot number): t, 4 ;y
i-akt ✓Vr1 /C SCA dit"Is / ✓ >> + J 0 ,2 4C C:7,)e LJ �IjbCy�
Directions to site - please include road names and numbers,, landmarks, etc.: L
`h/ii�v / �Lkr 1ALliol r /v.+� 5�r6�h: s�..1 /- �����✓i% �- /7�tvr. t / /`J
L1 1 0.7 /d S G tl��✓h�:' e ia, • 1c ✓11:2.-1. �c� SL v,� i." e
Ar. h f- Ile ./l',/ i.) C,, ) -e , I-,f 9 r /x t/t d-eAle
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): k/i i c /i 4 C *1110 6. 1'
6. Property size (acres): v 3
7. Lake/ river/ ocean adjacent to property: L�y%e c
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):, ^mss rtifR
t���� S1.71. /.� ,� /Cv'�"I� �i'r;1�.� + i /��� 4—ell
9. Will work be conducted from land? 2 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:
,e 1
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: S ��' s� �n f s 1,,� l,7 ✓� ,/�a�LO�� I ., SP�� 4
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): We 41 /y,
0&1 r G , n �a (� ��� C J' 1 '"'� i ✓ sP ry 7 .� y �[/ Zj / r� / �i-1
Owner /Agent's Signature A NCAC 02H .0502(f)1
Date
Agent's signature is valid only if on authorization letter from the owner is provided.
FORM: SSGP 10 -2013
Page 2 of 3

F.,
Lake
(At Full Pond/ Normal Water Level)
Full Pond/ -- �- ---
Normal Water Level °' I /
Shoreline ,e, Q 17
Vel
i
CIN
L't oy6
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ftx 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.
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corridors
FORM: SSGP 10 -2013 1 4 ='x r Page 3 of 3

REFERENCES: Lot 1168, Lake Royale Subdivision
Deed Book 1466, Page 827
Deed Book 1919, Page 491 - Restrictive Covenants
Map Book 12, Page 31
Tax Record No. 021052
LEGEND: 41 . . . . found iron as noted
O . . . . set iron as noted
- — — — — — — - . property line plotted from record
— . easement or buffer line
. . . . 100 -year flood limits line
NOTE: Area of Lot = 0.388 Acre ( Coordinate Method )
NOTE: 100 -Year Flood Limits line plotted entirely from DnRM
'Franklin County, NC', Community /Panel No. 370377
2831 J. effective 01/16/04
NOTE: N.C. Grid station unavailable within 2000' at this time.
NOTE: This survey is subject to all easements, agreements,
rights -of -way and restrictive covenants recorded prior to
the date of this survey.
No
LAKE
ROYALS
I, William T. Dement, Jr., certify that this map was dram under my superHefon from an
This document originally issued n October and sealed 13 William
actual survey mode under my supervision (deed description recorded in Book 1466, Page T. Dement, Jr., L -1458 on October 18, 2013
827); that the boundaries not surveyed are indicated as drown from information in Nap This media should not be considered a certified
Book 12, Page 31; that the ratio of precision is 1/20,000; and that this map meets document.
the requirements of The Standards of Practice for Land Surveying in North Carolina
(21 NCAC 56.1600). This 16th day of October, 2011
Professional Land Surveyor +L -1456
50' Tar River Basin
Riparian Buffer
Tie Line Only From Mog Nail
Set In Apparent Centerline
Intersection of Palomino Cove
h Sogarn Drhrc: \
S li4'13'25'E 316.72'
Now or Form"
Lake Royale Property Owner's
Association, Inc.
( D.B. 1803, P. 923 )
13/ f re, Rees
91't&-
nd Ssrdea
LAKE ROYALE
Nd Sol M Bas of
Found 3/4' Bat
Man Reb> a/fap
S' Brb tats
. Safaee Appros. a'
Frvn FIyY d toes
k1"
Set 112' Yen Pipe
is dace
Appm�
s• r
1'dgY or tRim
100 —Year Flood
i eC� Limits Line
Oda etC See Notes)
him or Formerly
Z
Paul Breitba het ux
D.B. 1024, P. 826) I
N 74'52'00'W
81.85'
Nor sot At Bose of
Fond 1/Y f}st Iron
Rabar ./Fw i' At,av4
txpwq Surface
•� ( 1166 )
1 N 16'13'301N
32.30'
1 Fond 3/4' son Near
&' b surrAb-
w
*I N 1516' l o "E
^ � \33.24' (1165 )
Feed 3/4' Yon R,bor
,/Top V ebae
QouM surf a
( 1164 )
PLAT OF BOUNDARY SURVEY FOR
JON SHELLEY WELCH & W FE, CANDY
(Properly Owner— Nancy Carrier)
107 Palomino Cove, Cypress Creek Township, Franklin County, NC
Scale: 1'= 60' Date: October 16, 2013
60 0 60 120 180
GRAPHIC SCALE - FEET
Surveyed do Mapped By
MALLIAM T. DEMENT, JR„ Prof eelonal Land Surveyor, PJL
L -1456, C -0649
919 - 496 -6159
102 West Nash Street Louisburg, N.C. 27549 (File No. 3602)
RECORD NORTH
( M.B. 12, P. 31 )
C. 1Pma- LCH

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCIUFTION: Df W 0* '"b
di JO
S--2-
NO. I l 6 S PLAN N0. a lt Z PARS- ID:
SZ
STREET ADDRESS: % % �d 1 m . �+ r� G �'�-� • l- o u S b i, i /
Please print: I G
Property Owner: I
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
����t ►�, kz�s , of plus 4641 /� L-C- L
(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 Owner's Address (if different than property above):
/ t7 J L4/i 11 acv r u� L! Gli-. , ��-ZU 2 SU Z
Telephone: -7 0 L — 7 2 7 — $ 7 b
We hereby certify the above information submitted in this appluation is true and accurate to the
best of our knowledge.
Auth rNed Signature
Date: 1- q - qzj i�
ee,
J
Auth Signature
Date: /— % Z

644
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