20140261 Ver 1_Application_20140320

Four copies of the application (including attachments) and the application fee should be sent to:
1
Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650
Applicant Information [15A NCAC 02H .0502(a)]
Owner
Name:
Mailing
PlY
F
LIAR 1 3 2014
i
-_ tNA7tk t�tiLiT ;
Telephone Number: _10q -q3 ()• P$y (ob Fax Number:
��(._
E -mail Address: e C R-A l fr( ),LOS+ C( +( -Z &t-5a C.&M
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.armV.mil/ Portals /59 /docs /regulatory /"regdocs /Permits /SAMPLE AGENT AUTH
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:
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,
FORM: SSGP 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: _ktgGOtiKCeirq Nearest Town: ( 120CJ
Subdivision name or site address (include phase /lot number): CcaiLO"i� 2,
IZSy Tslayp Creek `� 'L lyt Lod 13-SA MA,P 9(9 U3 9 ( 3
Directions to site - please include road names and numbers, landmarks, etc.:
(©i`,
Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): C� Q_�
Property size (acres): %g o—c � �e✓r�vw. a ) 35 74'X 1�3:6Y X (oy.Z3X (bj .
0
7. Lake/ river/ ocean adjacent to property: Tt (( e r-u
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): S�ntl7r��rz e 6"-A � } r-OK C AtCA f n&'-, i �u �f*0A J
51 Z' -t P IhCe Fop +r4.n z /za bode wA�th t�c� c Zc�«i 9' (nt4 NJ w'A
' (-,rt,2d
9. Will work be conducted from land? From water? El W �z
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:
No "i e
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: b'Ud . Zo y �-ee� 4 Ran Ito
12. Please describe the vegetation above the normal pool lake level/ Normal Waterq"ev and u' '
50 feet landward to be impacted (number of trees, for instance): SM ad i ilK u l
40,z CQ/t lay a. T eJZ $ 5 ,s c t9w tkL ba, -t.% .
Owner/ gent' Signature _[15M
Agent' sign tune is valid only if an
FORM: SSGP 10 -2013
Date
letter from the owner is provided.
Page 2 of 3

„ a \ z,,;
'(At Full Pond /No
FUid�a'�'°':: ..•w� ,. ,- mss, - gyp'.,, ,... �'h%�.L� °ry^• ��k�.:���T•
Norrnzd, Eater eve!° w
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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.
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 Page 3 of 3

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