20140736 Ver 1_Shoreline Stabilization_20140716

IJ— z u ® State of North Carolina
2 0 1 4 0 7 3 6 Department -of- Environment and Natural Resources
Division of Water Resources
r 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 ap licatio fee should be sent
to: ��
1.
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699 -1617
Applicant Information [15A NCAC 02H .0502(a)]
Owner I
Name:
Mailing
JUL 1 6 2014 �
Telephone Number: �(�.�3023 Number: `� "�
E -mail Address: V16cAK,v CLo Le rr
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorizati n letter (a form can be downloaded here•
http: / /www.saw.usace.army.miI/ Portals /59 /docs /regulatory /regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM. df) must be attached if the Agent has signed this application form.
Name: 5 i��2 iv S", / C""'
Company Affiliation: 13n kc Qoakk­
Mailing Address: PV 134j1 3b V
DJL
Telephone Number: kW- 4U -aC7 ?7 Fax Number:
E -mail Address: 41.401 A 6V V <A iA' -0-CAm
Person to receive the Certification Approval:
iJ_j
II. Project Info tion [15A NCAC 02H .0502(a) & (b)]
1. Attach vicinity ma e. street map) clearly showing the location of the property with
respect o oval Ian s such as towns, rivers, and roads.
2. Provide a deta ed site pla showing property boundaries and proposed locations of
vegetation clearing, structures (buildings, retaining walls, docks, impervious surfaces,
FORM- SSGP 10 -2013
Page 1 of 4

3
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.
Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale
of some sort- a yard stick, shovel handle, etc.)
Location of the property (where work is to be conducted)
(4:5&
County: �J Nearest Town.
Subdivision name or site address (include, phase /lot number):
5.
Latitude (in decimal degrees) 35JgJ Longitude (decimal degrees)
Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): � S1``E'G
Property size (acres): G i
Lake/ river/ ocean adjacent to property: 1 �`
8. Describe proposed work (include dismission as to how hardening of shoreline has been
avoided, or why it is necessary):
9. Will work be conducted from land? ❑
llCi
i46�
From water?
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the norm aIPool lake IeveI4 Normal Water Level in square feet or acres:
11. Total amount of disturbanU (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lak level/ N Water Level and 50 feet land -ward in
square feet or acres: J_
12. Please describe the vegetation above the no mal pool lake level/ Normal Water Level and
SO feet landward to be impacted (number of trees, for instance): _
1-0
Owner /Agent's Signature` [15A NCAC 02H .0502(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

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