20140470 Ver 1_Shoreline Stabilization_20140512

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State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
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DivLsion Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10 -2013
Shoreline Stabilization Application Form 2 0 1 4 0 4 7 0
Four copies of the application (including attachments) and the
Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650
Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: 41 i 13 - ttiwlA.J A/
Mailing Address: Q�O, 3 0 I
C- L a�'rl�.
PAID
to:
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Li In/ f f , F- 0,4 Cam_ k.,;
-.� 3&
Telephone Number: 47, 41 — 3 5O -5 45 Fax Number:
E -mail Address: i�3-t 1^ el'i 4-o /I 1 I °J C 49
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
nGrniT ni r
ORIZATION FORM.pdf) must be attached if the Agent has sig this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E -mail Address:
Person to receive the Certification Approval:
Fax Number:
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 the property (where work is to be conducted)
County: `1 c- ii S o ,� Nearest Town: '� �� fie �— °Z
Subdivision name or site address (include phase /lot number): L -c-, T— i
L --A rL Iw, u> C, c v 5 r-1 vdL C S j ,j 7 5' C. 3- 7
Directions to site -please include road names and numbers, landmarks, etc.:
r+ i
vie -! =>` d, 42 LeZ�_ W tN � N �u S� �.-� LG. =rI
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property: L C_ ^)
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): S 1Yi C, s rrm u� r� 5 -� c35 f •�r-.� t.`.� G-
e rw S r v •� '>'��J �cJ cru i jK ��� � r to ,it Oil
9. Will work be conducted from land? ❑ From water? LK
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: 3 � ( 5
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
SO feet landward to be impacted (number of trees, for instance): 't — 5' ��-
--!"4_c u 5 �.� { L, � f-� !1% O it L� '� t' �D'� 'Ji 5 t'uR -F�e D W o •c_e' IJ CX1e-
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Owner /Agent's Signature* [15A NCAC 02H .OS02(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

La ke
(At Full Pond/ Normal Water Level)
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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