20140387 Ver 1_Shoreline Stabilization_20140415

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® ®I State of North Carolina
D % ■ �'n Department of Environment and Natural Resources
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Division of Water Resources
Division of Water Resources 1SA 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 D �� 'n'
Raleigh, NC 27699 -1650
APR 1 5 2014
I. Applicant Information [15A NCAC 02H .0502(a)] 504k - WATFA OUAO'
1. Owner Information w r�:•.
Name: C r e.cr R P e/J
Mailing Address: Co 1 -t lc ✓n e-e&
F11 19 IL.h ¢- - -"/ . c,
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Telephone Number: Q I i -- SOS-- kf70 Fax Number:
E -mail Address: Ct- ex
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: s ;e--e 0C_ f c,
Company Affiliation: PX /J 4D�? �� C 74
Mailing Address:
Telephone Number: .2 S-2-- � 7d�'- Fax Number:
E -mail Address: ',�Yr o ,4- k 3 3 P- eS) i i 7, e-'c ,,;A
Person to receive the Certification Approval:
11. 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: Nearest Town: "V
Subdivision name or site address (include nhase /lot number): Zof ks J
Directions to site - please include road names and numbers, landmarks, etc.:
F1_0 N t" 7 i14e
i iV'ae.AV SA��ctc?n_� n.1
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): /t of '� d c17
6. Property size (acres): '.53
7. Lake/ river/ ocean adjacent to property: )_ �"-' " ,y,-1 -e
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): ,��/�e /fir. 11 ,r«s , � 1W'
9. Will work be conducted from land?
From water? ❑
10. Total amount of disturbance (including all excavation, backfili, rip rap, retaining walls, etc.)
below the normal pool lake level/ Normal Water Level in square feet or acres:
b(.!'u�j'/"•'��,Lje i Ri.�Sf/: wn / j %C �,Ej/' � i�TV /�.+��i� �{l a w� iC ��f u• i�'RnJ/ ,.. �r. /_fr =%i � �'Mi?
/ /' fA'N 61 /.T
11. Tota amount of �isturbancc(inclu ing 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 q
square feet or acres: C le.'4-r 3 7.
12. Ple se escrXe the vegetation above the normal podi %akele�lr ormal Water Level and
50 feet landward to be impacted (number of trees, for instance): _v4 - -
T rL' m � bl.0 .^ i� c- � V`� '��' L'c;.r•E' }U�US m ` r � -� ` " i L C�'�W a { l�
A '/_0 aeovi-ee"I . '-/Y-4
Owner /Agent's Signature" [15A NCAC 02H .0502(f)l Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10 -2013 Page 2 of 3

Provide four (4) copies of the application and supporting information (maps, drawings, etc.),
as well as the appropriate application fee (see below), to the Division of Water Resources,
401 & Buffer Permitting Unit, 1650 Mail Service Center, Raleigh, NC 27699 -1650.
A' plicant Information
Owner Information: Please provide complete and accurate contact information
Agent Information: Per 15A NCAC 02H .0502 , an agent may be given signatory
authority for the owner /applicant if a signed and dated copy of an Agent Authorization
letter is included with the application. (A sample form may be found at
http: / /www.saw.usace.army. mil / Portals /59 /docs /regulatory /regdocs /Permits /SAMPLE
AGENT AUTHORIZATION FORM.pdf)
Pro'ect Information
Vicinity/ Site Map: Some type of site map so that someone unfamiliar with the area can
locate your project. A county map or USGS topographic map indicating the project
location is usually sufficient.
Site Plan: A site plan showing the location of the shoreline, location of the impacts to
the shoreline and /or lake bottom and the location and any vegetated areas that will be
impacted. In most cases the site plans do not have to be professionally prepared.
However, if you intend to conduct hydraulic dredging, professionally prepared drawings
will likely be required for the spoil structures. See example below.
❑ . Photograph of shoreline to be impacted/ disturbed
Description of property and existing features on and near the site
0' Description of project and impacts/ disturbance proposed
III. Signature
© Per 15A NCAC 02H .0502 , the application shall be considered a "valid application" only
if it bears the signature of a responsible officer of the company, municipal official,
partner or owner. This signature certifies that the applicant has title to the property, has
been authorized by the owner to apply for certification or is a public entity and has the
power of eminent domain.
IV. A plication Fee
The application must be accompanied by the appropriate application fee (checks made
out to the NC Division of Water Resources). The application fee is as follows (pursuant
to G.S. 143- 215.3D):
➢ $240.00 for impacts to lake (below normal water level) of less than 1 acre
➢ $570.00 for impacts to lake (below normal water level) of greater or equal to 1 acre
INSTRUCTIONS FOR APPLICATION SSGP307980 08 -13 & SUPPORTING DOCUMENTATION Page 2 of 3

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Driving Directions from 101 Cheyenne Dr, Louisburg, North Carolina..
Notes
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Trip to:
611 Sagamore Dr
Louisburg, NC 27549 -9585
0.94 miles / 2 minutes
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101 Cheyenne Dr, Louisburg, NC 27549 -9149 F ee App
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f+ 3. Turn right onto Seminole Dr. Pvjlai_� 0.2 Mi
0.7 Mi Total
4. Turn right onto Sagamore Dr. Nfi� m 0.2 Mi
0.9 Mi Total
5. 611 SAGAMORE DR.
611 Sagamore Dr, Louisburg, NC 27549 -9585
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Driving Directions from 101 Cheyenne Dr, Louisburg, North Carolina..
Total Travel Estimate: 0.94 miles - about 2 minutes
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