20140699 Ver 1_Shoreline Stabilization_20140707

State of North Carolina
Department of Environment onment and Natural Resources
! 5 A3
%� Division of Water Resources
Division of Water T _ *1155A NCAC 02H .0500 — Water Quality Resources � Q rtY Certification, Shoreline Stabilization
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
1617 Mail Service Center
Raleigh, NC 27699 -1617
Applicant Information
1. Owner Information
Name: r, d v-e w L e e- S ke ✓r, ) i
Mailing Address: D,509 Sow L11 , 69,r p
L�OW"L
v
JUL i; 7 2014
o NR - WATM QUALITY
Telephone Number: UL 381 - 1303 Fax Number:
E -mail Address: gn�►rr�.✓ �e�r'1 f {,o -� J, co'"
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
must be attached if the Agent has signed this application form
Name: �t o n e-
Company Affiliation: N D N E
Mailing Address: _
Telephone Number: Fax Number:
E -mail Address:
Person to receive the Certification Approval:
II. Project Information [ aa3L -a c iy de P-ocJ ] Ga wbA� N C D F60q
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: _ C "\ +-g"o` Nearest Town: C g% k w b c,,
Subdivision name or site address (include phase /lot number):
A i
00V,e_ -T,•. Loo 441`7 . C1
Directions to site - please include road names and numbers, landmarks, etc.:
R di we S'>t . Tv r.� r ; cy in-f a -� -j-,o e -ui) P s-o✓ e
51�e11 S+,4,y,1 oh-6 13-4 ly SLctt/t Q-4 fb.- L-I M:IeS, cro s e,�ye
ge l S4- ro a J o i
Latitude (in decimal degrees) r r Longitude (decimal degrees) gv, aa5ogq
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): r es 'I
6. Property size (acres): . 51
7. Lake/ river/ ocean adjacent to property: La ke. N c> - A,.�
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): = /) S O -%,4 b , cJ Je
�n v I C kI„ U - oO4 o-f r
9. Will work be conducted from land? 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:
3fee+ X 105 fee- _ 315 SF
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: l*� 1 Sc,> s F7 ��„ cIJoS 6 3o sF o-t R;p /o5 'x X19
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): % /SO sr-
0 f e- xZ 1�, � rc s c %_', (I J e c o �e� ,,,, r►-, ,�1 ct, ,
J
Owner /Agent's Signature* [
Date
6- __�r7 - -) 0j61
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10 -2013 Page 2 of 3

A a,�lreSS� aa3� G��de a °0`� i Lq ��i �L a 9669 r
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FUll'Pond/
Normal Water Level
Shoreline
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(At Full Pond /Normal'Watertevel)
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Please approximately- sketch the following information on this plan (provide dimensions for each
item,.such,os 10 ftx 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 ofrip ,raptor fill to tie - placed below the Full Pond/ Normal Water .Level' elevation
4. Location,of any proposed structures' such—a"s�bu'ildings,'ret'aining walls; - docks; etc.
5. Location of any excavation or dredging ;below the Full Pond /,Normal Water'Level elevation
6. Location of construction access corridors Q �e�►o�+es �e�-��bn o`� y w•�loMr a'°�`lCS
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THIS 15 TO CERTIFY THAT ON THE
3�5� DAY OF MQ-- y _1989 I`
SHOWN ON THIS PLAT, AND THAT THE TITLE LINES AND 7HE I. SURVEYED THE PROPERTY
SHOWN HEREON. WALLS of THE BUILDINGS IF ANY ARE I
Revised.' 6 -6 -89
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SIGNED
REGIST RED YOR
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