20140700 Ver 1_Shoreline Stabilization_20140707

$�PAW 20140700
State of North Carolina
nUAID Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 —Water Quality Certification, Shoreline Stabilization
Division of Water Resources 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
Raleigh, NC 27699 -1650
Applicant Information [15A NCAC 02H .0502(a
1. Owner Information
Name: {V�r��.. S��Y.c. G,y„h�ry ov � =-1. -C
Mailing Address: {Z-
C T\ rl =,
7%
tuft - VVNTIER QUALITY
Stormwe4r Branch
�. _..may --..
Telephone Number: 70y 'AM `yJV5 Fax Number: 704 - 9 ` J -` 1ftj
E -mail Address: W45 Q_ t-4,--o 1;.,,. , rr . Ca
T
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
htto: / /www.saw.usace.armv.mil/ Portals /59 /docs /repulatory /repdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation: ce_cAor I (Atby 4 �i��►.��h°►nK
Mailing Address: �S YD I 1Ju ���- Sr�o�,, D40.-
Telephone Number: 704 14V-*i A5 Fax Number: 104 -14V- 44 a9
E -mail Address: ks s Q fk4ra S;r a .tr, C-0 V",
Person to receive the Certification Approval: Zlr �. S a • t1. cj
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: 55GP 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: ►1v��t +S v, `lam
Subdivision name or site address (include phase /lot number):
Directions to site - please include road names anQd` numbers, landmarks, etc.:
1'�u�1.. �``�,. LIOSLiS� 5�3��►`V,�S�C►� 1� ^- �3 �CACJ�G.fi�t 1.1�.•
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Gz ��► �.o�fss
6. Property size (acres): akg
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): "* qV :X11y rCL�S i'v �w }�.. L-i5:J _ `' Cc 4, st
sa �.:as;a �, ��� haw �►�,� p,o�1 +.,��s ;r10 �.'��r. L�k.� d
9. Will work be conducted from land? ? water? ❑
Ll" 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
i
square feet or acres: �,O j,,ot. ra 6g,
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): V'c At,_
Q , 1
b � r w��o � +LvnAS �w:n�. � 30 � 1
Owner /Agent's Signature [15A NCAC 02H .0502(f)) Date
yAgent'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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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 72013 Page lof'3
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�,''v� =•v v {f` Y l}.M ki .s'v F '_4v �J,t ^`� _
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 72013 Page lof'3

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