20140208 Ver 1_Shoreline Stabilization_20140304

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
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I. Applicant Information [15A NCAC 02H .0502(a)] �.�. -�r ' ---
1. Owner Information
Name: Sandra H Bigner
Mailing Address: 5131 Corbett Ridge Road
Mebane, NC 27302
Telephone Number: 336 - 562 -4242 Fax Number:
E -mail Address: wbigner @aol.com
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
h _ttp_: / /www.saw.usace.armv.rniI/ Portals /59/ docs/ reguIatory /regdocs /PermitsjSAMPLE AGENT RUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E -mail Address:
Person to receive the Certification Approval:
FORM: SSGP 10 -2013 Page 1 of 4

H. 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, structures (buildings, retaining walls, docks, impervious surfaces,
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: Person Nearest Town: Semora
Subdivision name or site address (include phase /lot number):
Lot 9 Pinesborough Estates
Directions to site - please include road names and numbers, landmarks, etc.:
From Roxboro North on Hwy 57. Right on Zion Church Road.Left on Pinesborough
estates Rd. Lot 9 on right.
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): residential
6. Property size (acres): .735 acres
7. Lake/ river/ ocean adjacent to property: Hyco
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Bulkhead construction — treated wood
9. Will work be conducted from land? yes From water? yes
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:
retaining wall 880 sf +-
FORM: SSGP 10 -2013
Page 2 of 4

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: 2200 sf +-
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): scattered pines,
approx 30 total — small saplings
1161
Owner /Agent's Signatefre* [15A NCAC 02H .0502(f)] Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
Full Pond/
Normal Water Level
S
La ke
(At Full Pond/ Normal Water Level)
FORM: SSGP 10 -2013 Page 3 of 4

Full Pond/
Normal Water Level
Shoreline
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Lake
(At Full Pond/ Normal Water Level)
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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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Roxboro, NC to Pinesborough Estates Rd, Semora, NC 27343 - Google Maps Page 1 of 2
To see all the details that are visible on the
screen, use the "Print' link next to the map.
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Map data 02014 Google -
Driving directions to Pinesborough Estates Rd, Semora, NC 27343
A Roxboro, NC
I. Head west on Depot St toward N Main St
138 ft
2. Take the 1st left onto N Main St
0.1 mi
3. Turn right onto Gordon St
0.2 mi
4. Take the 2nd right onto Madison Blvd
433 ft
5. Take the 1st left onto NC -49 S /NC -57 N
0.4 mi
6. Slight right onto Concord Rd
0.2 mi
7. Continue onto NC -57 N /Semora Rd
10.9 mi
8. Turn right toward Zion Level Church Rd
0.1 mi
9. Turn right onto Zion Level Church Rd
2.6 mi
10. Turn left onto Pinesborough Estates Rd
1.0 mi
g Pinesborough Estates Rd
Semora, NC 27343
https: / /maps.google.coml maps ?hl= en &g1= us &authusei = 0 &q =hyco +lake &ie= UTF- 8 &hq =... 2/13/2014

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