20140382 Ver 1_Shoreline Stabilization_20140414

20140382
PAID 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 0 LPR
401 & Buffer Permitting Unit
1650 Mail Service Center 4 2014
Raleigh , NC 27699 -1650 rR
I. Applicant Information [1SA NCAC 02H .OS02(a)]
1. Owner Information
Name: Cher
Mailing Address
m i 7_14
Telephone Number: Fax Number: v,+-
E-mail Address: C_UkT.smrr4Cd hC Cc--,
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 AUTFI
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: /3 bos N( A-r?-Tt n, / 5 FA_f � 4-C L_ C G
Company Affiliation:
Mailing Address: 0 J3?3 X .30
(r&&: iy ✓lC(_ 5-, xi , C' . 2- 73
Telephone Number: 828 -226 Z 6q 7 Fax Number: '7y-3 6,. fib
E -mail Address: aaoDcz'6 oo .Sd C@ 0�0 I, co 01.
Person to receive the Certification Approval
C t),P r s rk7 rr;-/
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 of t,,,,h /�e property (where work is to be conducted)
County: lwt-to/,./ Nearest Town: /�-a Ua Nom_
Subdivision name or site address (include phase /lot number): 32-7 UPPIE-e
l�Jk_►y OT_ 7)22£- L N
Directions to site - please include road names and numbers, landmarks, etc.:
l �1 S W ",f4 IQ-6 Fla N. C 7-D 04 1, tvu i
LN OW I- tzi= TiA9L l3o�L/�►+�D! % t� atreAe toh,L^Jvr
i e c.N a N csj--T F;--k fo 307
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): 6'n ir s iTi,c-
6. Property size (acres): t —
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why It Is necessary): 7?6 S -wr& z-E S ,402E c
9. Will work be conducted from land? ❑ From water? [9
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:
�" S cd-
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: �Wo S Q
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): /*46 7)b69-S Oft
BQ _c_a %d /3E 11r)11A-eEb Rroq -use 1- ?%�c e2E5,K;7- Sim AWIVC
/.S /W 7)Ve4 1V.C9*- ,_0,0W
Owner /Agent's Signature* [15A NCAC 02H .0502(f)] Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10 -2013 Page 2 of 3

Latitude and Longitude of a Point Page 1 of 1
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