20140655 Ver 1_Shoreline Stabilization_20140627

2 0 1 40 6 5 5
State of North Carolina
PAIDDepartment of Environment and Natural Resources
DWRDivision of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: SSGP 10 -2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit i - -��
1617 Mail Service Center
Raleigh, NC 27699 -1617 JUN,
1. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information //
Name: &&,-, led _
UNWA
I.ti_.
Telephone Number: %4�-r �� y -g- 3�JcR_ Fax Number:
E -mail Address:
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.pdfLmust be attached if the Agent has signed this application form.
Name: fame;
Company Affiliation:
L
Mailing Address: RrnWn'A 1comatr ictina
104 EWgwood Imoe
Mt GiiW4 NC473ft
Telephone Number: 916 -VS I _ Fax Number: 9la4/1
E -mail Address: t, �� ®I) ,2 N �
Person to receive the Certification Approval: rt =-
11. Project Information 115A 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 pr pe (where-work is to be conducted)
County: �2,v7 Nearest Town: %�27"i� 1� 6ms
Subdivision nam or site eddress (inclu a phase /lot number):
- d ?
Directions to. ' e - please include road names and n tubers, landmarks, etc.:
5.
Latitude (in decimal degrees) Longitude (decimal degrees)
Describe the existing land use or condition ZY2 f th ite the time of this application
� (residential, undeveloped, etc.):
6. Property size (acres):
7
Lake/ river/ ocean adjacent to,properl:y:
8. Describe proposed work (include discussion as to how
avoided, or
x
9. Willwork b
of shoreline has been
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 amoun of distur ante (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal ool lake level / No al Water Level and 50 feet land -ward in
square feet or acres: tl
12. Please describe the vegeta ion abGvfe the normal pool lake4vel/ Normal Water Level and
50 feet landward to be impacted (number of trees, for instance):
Bro"°s Construction
104 DWwood Lane
Mt Gilead, NC,27306
13`_ 910- 43g-13d4 _1 4 ;e / " 7
Owner /Agent's Signature [15A NCAC 02H .0502(f)j Date
Agent's'signature,is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10 -2013 Page 2 of 3

Full Pond/
Normal Water Level
�t i i
Shoreline
Lake
(At Full Pond/ Norm at Water Level)
i
f
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.
S. 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

I of 1
6 -10-14
Brown's Construction
104 Dogwood Lane
Mt Gilead N.C. 27306
910 -439 -1384
I Billy Hendricks give Butch Brown, of Brown's Construction my,permission
to act as my agent in securing permission, permits and construction to be
done 294 Springwood Drive. Mt Gilead M C 27306.
Billy Hendricks
Date (-/?- l

Montgomery County, NC Print Map
...20A1
2198
�.17AI
Page 1 of 1
Montgomery County, NL
Disclaimer. The information contained on this page is taken from aerial mapping, tax mapping, and public records and is NOT to be construed or
used as a survey or'legal description'. Only a licensed professional land surveyor can legally determine precise locations, elevations, length and
direction of a line. and areas.
Parcel Number: 6574 12 85 2164
Name: HENDRICK, BILLY & DENEICE
House W 294
Road Name: SPRINGWOOD
Road Type: DR
Address 2: 6103 PHILADELPHIA CH RD
Address 3: MARSHVILLE, NC 28103
Parcels
Deed Book: 656
Deed Page: 233
Lot Number: LOT 4; MAP 8
Legal Description: FAIRWAY SHORES
Sale Month: 04
Sale Year 10
Total Market Value: 273700
Land Value: 142560
Building Value: 105076
Year Built: 1968
Appraisal: 01
Attributes at point: N: 545201,
E: 1678333
Fire Districts
Townships
Proposed Voting Commissioner's Districts
Name; Tl{ery
Name: PEE DEE
District 1
Zoning
Voting District Precincts
Zoning: Residential 1
Name: PEE
City:
Watersheds
Class: WS-IV
Name: Lake Tillery
River Basin: Yadkin
htfD' /hw y.webdis n.''. Anderson 6 Associai . sm. .. _'•'•W+. i��uzu�u: wie�
init: Start
init: done
http: / /arcgis. webgis .net /ne/Montgomery/printable.asp 6/22/2014

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