20140419 Ver 1_Shoreline Stabilization_20140428

i 40 4 i g
U S. ARMY CORPS OF ENG94EERS
Form Approved -
APPLICATION FOR DEPARTMENT OF THE ARMY PERWT
OmB Na 07104003
I
33 CFR 325 The proponent agency is CECW -COQ
Fapft& 31-AUG1ST -2013
Public reporting for this collection of labination s estimated to a%emp 11 hays per response, including the time for nevfavnrg instructions. seam" -
etdstovg data sotuces, gafhedng and maintaining the dam meded, and oomple M and ra+Aewbg lire co@adion of mbmuabon. Sertd ownmerta regartting
this burden estimate or any omen aspect of am collection otoftbtrtialiott, including suggestions, for reducing this burden. to Deparbnent of Defiww.
Wastdrigbn Headquarters, Executve Services and Cortraprvrabons Dbedmat% kam nason uwmgwnmd Oimian and to the Office of Management and
Budget Paperwork Reducbon Project M7i0 -=l)_ Respondentfs should be aware that narlu materdhg any other provwon of law, ro person shall be
subject to any penalty for f ing to txbrlplywith a collection of rdartatlar [fit does notdispby a currently vafid 0108 control tnrrber Please DO NOT
RETURN your fam to etitter of arose addresim ComphJed appfinabons mtst be stbnmftd to the Dfsttict Erlgbvw ►awg jL 6 over the bcaflon of
the Proposed activity
PRA/ACYACTSTATEMENT
Authorities lbvem and Harbors Act, Section 10.33 USC 403. Clean Water Act, Section 404, 331,= 1344: Marine ProtectIM Rewind; and Sanchmries
Ad, Section 103.33 USC 1413. Regulatory Pmgrdm of the Corps ofErpneem Final Rule 33 CFR 320332 Pnrripal PLrpose: b>t mUmmr proaAied on
tits form via be 1set1 m evakebng the appkabon for a pem k Ratbm (Ater This tdmrnabort may ba dmWv ith Ste DepaMnrerd Of Jrmtice and oR-
federal. state. acct local governmerit agendas. and the public and may be made available as port of a public notice as n:pulred by Federal aw Stbndsalon
of requested intimation is voluntary, however, d indornnakin is not provided the perett app&a8oru carrwt be evakeded nor can a pemd be Issue(. One set
of ttrgrnal drew gs or good reproducible copies; wtddl show the bcation and character of the posed activity crust be allachad to ttrs application (see
sample drawings and/or instructions) and be st6rmftd to the District Engineer having jtrWmamt Inver the bpfimn of the proposed adtivdy An appirafont
that is rot cornpteted in full will be returned
MEALS I THRU 4 TO BE FILLED BY THE CORPS)
1 APPLICATION NO
2. FIELD OFFICE CODE
13. DATE RECEIVED
4 DATE APPLICATION COMPLETE
(!TENS BELOW TO BE FILLED BYAPPUCAIM
5 APPLICANTS NANIE
a AuTHORmD AGENTS NAME AND TITLE (agentns not required))
Fast - J -4w, Uddle- /gGLeI4 Last- tf -eael
Firms- 3f-& -f Mme- W--fk� Last- i704-
Cmnpany- -700
c,,. lcn! f
,
Einad Address - 1O
,_
E-addes- �0
6 APPLICANT'S ADDRESS-
9. AGENTS ADDRESS-
Address- L{vlb
Address rq, C• oS`
?S v! er r /cn
city - ?I ?svaEr/f Ste- 71•C• zip
a
City- Sate- iVir'. Z4p- Country -
isslr2CounU'itSl!
.Q _,.IAI
7 APPLICANTS PHONE NOs vWAREA CODE
10 AGENTS PHONE NOs w/AREA CODE
a Resrderxa b Btstrim e. Fax
a. Residence b Business c Fax
STATEMENT OF AUTHORIZATION
11 1 hereby authorize. $ to ad in my behalf as my agent in go Voceseing of this application and to hnndah Won request
suppkrner" Infbiviaoon In wAVort of this pemat appScabon.
SIGNATURE OF APPLiCA DATE
NAME, LOCATION, AND DESCRWTRM OF PROJECTOR ACTWITY
12 PROJECT NAME OR TITLE (see ms1nrdlons)
(! t- ; W ; e r1 <h
13. NAME OF WATERB/O�DY, IF KNOM (tfapokable) 14 ROJECT STREET ADDRESS Ofappreable)
4lift In o n e [mil
L 4 /t ° Address 13" ,5-
15 LOCATION OF PROJECT City - /0 v s tI v� Stae -v � G, zv- o27SSj
Labtude •N )If& Lmgittow •W 2110
10 OTHER LdCATM DESCRIPTIONS, F KNOWN (see tent as)
State Tax Parcel ID Municipality
Section - Township - Range -
ENG FORM 4345, JUL 2013 PREVIOUS EDITIONS ARE OBSOLETE.
Page 1 of 3
APR 2 8 2014 I

DWR State of North Carolina
Department of Environment and Natural Resources
_ - Division of Water Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification
Instructions for Application FORM SSGP 30 -2013
(Shoreline Stabilization 401 WQC to accompany USACE GP30, GP79, or GP80)
Instructions for Shoreline Stabilization Application
When to use this form —This application form should be used to apply for a 401 Water Quality
Certification to impact:
Description
U.S. Army Corps of
Engineers (USACE) Permit
Federal Energy Regulatory Commission (FERC) regulated lake
shore or bottom
GP30
Tennessee Valley Authority (TVA) regulated lake shore or bottom
GP30
Local government regulated lake shore or bottom
GP30
USACE Reservoir owned /regulated lake shore or bottom
GP79
Private lake shore or bottom
GP80 ,
When this form should not be used — This application form cannot be used for wetland or
stream impacts. This information does not apply to landowners within the twenty coastal
counties that are affected by Division of Coastal Management (CAMA) rules.
For more information — If you have been advised that you require a 401 Water Quality
Certification, and would like more information about:
➢ The application process: http•/ /portal ncdenr ore/ web /wa /swp /ws /401 /certsandpermits
➢ How to download an application form:
http://Portal.ncdenr.org/web/`­wa/`swi)/`­ws/­­401/certsa nd Perm its/a oply/forms
➢ Application fees:
http•/ /portal ncdenr ore/ web /wa /swp/ws /401 /certsandpermits /apply /fees
If you are unable to download this information or application, please call (919) 807 -6300 to
request an application with instructions.
Please note — Not all impacts require written authorization from DWR. This may include the
construction of docks or boathouses if there is no dredging or filling involved (other than the
pilings). For more information, please visit the following website:
http://Portal.ncdenr.org/web/wQ/­swp/­ws/401/c-ertsandoermits/
faqs#always have to apply
How to apply — When submitting an application to DWR, please use the following instructions
as a checklist in order to ensure all required items are submitted. Adherence to these
instructions will help facilitate a quicker review time and reduce the amount of requested
additional information.
INSTRUCTIONS FOR APPLICATION SSGP307980 08 -13 & SUPPORTING DOCUMENTATION Page 1 of 3

20 140 4 1 9
State of North Carolina
Department of Environment and Natural Resources
D� R
Division of Water Resources
- W
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 v I
Raleigh, NC 27699 -1650 APR 2 8 2014
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name- , �c1 rn�5 A LUN t4,P1Lfr- -
Mailing Address: 4t-01r)
y> ,eA-'
Telephone Number: �:tszl ���- 4-7 68� Fax Number:
E -mail Address: a LLI',v
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 /reedocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM pdf) must be ttached if the Agent has signed this application form.
Name: St P Z� 0 �Z
Company Affiliation: P h; L's (V u J2
Mailing Address: -V >0
Telephone Number: �a gT V ztgA. Fax Number: »�p
E -mail Address:
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 5SGP 10 -2013
Page 1 of 4

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.
Applicant Information
EJ 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_ :Hwww.saw.usace.army.mil/ Portals /59 /docs /re ,gulatory /reRdocs /Permits /SAMPLE
AGENT AUTHORIZATION FORM.pdf)
II. Project 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.
Q Photograph of shoreline to be impacted/ disturbed
Description of property and existing features on and near the site
QQ' Description of project and impacts/ disturbance proposed
Ili. Signature
Q 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. Application Fee
Q 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

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: /= r,.„. k- I,,/ Nearest Town. 13 ci r►r
Subdivision name or site address (include phase /lot number):,
Directions to site -please include road names and numbers, landmarks, etc.: f=r�•n t
_IS&Jl .f S-( C a)14c1r-0 t-LI vAi L- •.. --4:* `i- Sie v B/y
Saga 323 ,; PI For
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): i k /, t-1 a L
6. Property size (acres)- C,`) 7 Re, / -e5
7. Lake/ river/ ocean adjacent to property. La
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): �,,„„�� 7►, -,5 t)v2, T_. howl.., * w4 tr, wal
J-- /v L, CdN?itiiN t40 9ti-c, •vndk� Lot Lo<y6U,
9. Will work be conducted from land? 0'" 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 in square feet or acres:
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: 66cel SIC 5caain0r 3o'im Ste. Lr'„ r
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)- 3 7r•_y s wr cL U >
114-1,1Z 3-' � --' `J'? et,. ,.15 _-41,, Sa f.P t-11 #q-Pe 50A/s , blAr A.P !1 ; f 02%.0 aAcL
Aue-t 5 � S�-fh" 710 i /`fv ��oo/ Shat
Owner /Agent's Signature' [15A NCAC 02H .0502(f)]
4jyj _ell
Date
'Agent's signature is valid only if an authorization letter from the owner is provided
FORM SSGP 10 -2013 Page 2 of 3

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