20140795 Ver 1_Shoreline Stabilization_20140728

State of North Carolina
- 2 0 1 4 0 7 9 6epartment of Environment and Natural Resources
DWR Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification .Shoreline *Strbilization
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
13 _ U 'p al#
Raleigh, NC 27699 -1650 I - -- �---- U
I .j1JI " E
i.J f li I'f
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information Lv4
ke? ; Stp orrnwat� �r Branch
Name: Gregory S Rushing
Mailing Address: 1445 North Main Street Mooresville, NC 28115
Telephone Number- 704 - 717 -0127 Fax Number:
E -mail Address. grushing @carollna.rr.com
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 armV.mil/Portals/"­59/docs/regulatory/regdocs/­Permits/SAMPLE AGENT AUTH
ORIZATION FORM pdf) must be attached if the Agent has signed 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
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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. Stanly Nearest Town:
Norwood
Subdivision name or site address (include phase /lot number)-
Lake Tillery Estates
Directions to site - please include road names and numbers, landmarks, etc : _
From Highway 24/27 —turn right onto Lake Tillery Road. Then turn left onto
Robbie Road. The house is at the end of the road
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): residential homes develope
6. Property size (acres): 23 acres
7 Lake/ river/ ocean adjacent to property- Lake Tillery
8 Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
Going to clear the shoreline and grade and place rip -rap
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.
75 88' x 4 = 303 52 / 43,560 =.007
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: 75.88' x 4' = 303 52 / 43560 = .007
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). Wooded with Native
Species with Pine Oak & Other Hardwood. Approximately 12 -15 trees
J /
Owner /Agents Signature* [15A "C 02H
FORM SSGP 10 -2013 /
X57 36 7v :FI
OL/.0��1
July 21 2014
Date
Page 2 of 3

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APPENDIX F
Minor Rip Rap Stabilization
DTICAL CONDITIONS
12" TO 36" ERODED CUT
WAVE EXPOSURE
Is]
STING GRADE
ASS 1 RIP RAP
LAKE_
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