20140362 Ver 1_Shoreline Stabilization_20140410

2 0 1 4 03 6 2
State of North Carolina
�artment of Environment and Natural Resources
DWR
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources 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: Z4CK
Mailing Address:
,�( t
APR 1 0 2014 p i
tA - -___I
WATER ctlAL11Y
:51-Ei f1s �d . N C 28673
Telephone Number: 76d -Y5-6-c,,71_3 Fax Number:
E -mail Address: 2• h e7iVCY -e Ott rA MDLWTS rAFF %/y!iIyc • cem
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 /regulatory /regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: Zs4CK #EFA(EEA,'
Company Affiliation:
Mailing Address: qJ(v / R; V / e-1r a-- Dr-
S14,E- rr; lis PortA _ N C Z F673
Telephone Number: q- Z/56 -�l3 0 F-ax Number:
E -mail Address: 2!1 If A/C r @ PA? _2 �^0�5 A
Person to receive the Certification Approval: Z,r4CK f-
i rJ4 /V C . C-0 h_\
II. 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 ofthe /property (where work is to be conducted),
County: C���k44 Nearest Town: '__MP+C'r'; 'Il.s Fo'r'd
Subdivision name or site address (include phase /lot number): % 5 6
/Riyi e..rA
Directions to site - please include road names and numbers, landmarks, etc.:
50 W -Fr bnn Mooresv f- "f- Z)N 5ACV-61ts O Rd4.
D N 1L 5 �v4+v a i'4 + R y` Dad v I r.
�+
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): V'C5i Ae 41 X h,BMt w 14, pit ✓. q'rA,55 ;f1VSI 0.J
6. Property size (acres): . 78
7. Lake/ river/ ocean adjacent to property: I- AKe- Ho rM °4nl
8. Describe proposed work (include discussion as to how hardening of shoreline has bee
avoided, or why it is necessary): // WleAl h4ue -wA'14 -A pyra biros ;oA)
9. Will work be conducted from land? R 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;iwsquare feet or acres:
3' x sc) ' -
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: 1- Z Ix 5e
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): -hLe•00'c *Jo
+re-eS , i v_s" _ 4 (r oo 155' (Scc 064o s)
6'ee N
Owner /Agent;s Signature*
[0= 0711%
reI
Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM. SSGP 10 -2013 Page 2 of 3

has been avoided, or why it is necessary): c.,4 ` 2- -IM;.Z
• Will work be conducted from land ? /M,c From water?
• Total amount of disturbance (including all excavation, backfill, rip rap,, retaining
walls, etc.) below the normal pool lake level/ N rmal Water Level in square feet
or acres: a
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap,
retaining walls, etc.) above the normal pool lake level/ Nor 1 Water 'Level and
50 feet'land -ward in square feet or acres: S� ,G
12. Please describe the vegetation above the normal pool lake level/ Normal Water
Level and 50 feet Ondward to be impacted (number of trees, for instance):
3 -al 7- ao11
Owner /Agent's "Signature' r15A NCAC 02H .0502(f)l Date
Agent's signature is valid only if an authorization letter from the owner is provided.
3

Full Pond/
Normal Water Level
Shoreline
T'ICII
�b
I
4
,J h
1A
L v
�v
V
Lake
(At Full Pond/ Normal Water Level)
50
qk ca-lb
3 b'\a'uj
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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9561 Riviera Dr, Sherrills Ford, NC - Google Maps
G!l Address 9561 Riviera Dr
oI.)g a Sherrills Ford, NC 28673
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