20140819 Ver 1_Shoreline Stabilization_20140801

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2 0 1 4 0 8 1 y State of North Carolina
Department of Environment and Natural Resources
R Divisio of Wer a ces
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15A NCAC 02H .0500 — Water Quality Certification, reline Stabilization
Division of Water Resources FO 3
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, INC 27699 -1650
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: At, Gl (e X a Vri
Mailing Address: /Jr .-
',.s w ,e //, CA
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AUG 0 1 2014
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Telephone Number: `700 6y2-Liots Fax Number: r1 i0
E -mail Address: joA , b e- rzw� Q, U eT yZoL, t,-, .V-Q_ttss , C o,r,n
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 /dots /regulatory /regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if t e //Agent has signed this application form.
Name: N14 /4'k"e S'e ✓.1 ✓:( Cam - ✓cc M✓-
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E -mail Address:
Person to receive the Certification Approval: G S 6- 44V e__ — S hr Gr-c q w.
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

3s1 93 llo I
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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 ofthepro the property (where work'is to be conducted)
77—,ac,
County - V rS�O'`^ Nearest Town r, AP ��2 / IN
I
Subdivisip- ame or�site address (include phase /lot number) /7oS eVuo� 1%& A4,-*
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o -frs /-e j NC 9Q7 Z3 1-07 9 U»,* �
Directions to site - please include road names and numbers, landmarks, et
tie Pa. /0-) — .r, G_ r rlv GtJv des `%%v �� 2", 7sr_ J
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5 Describe the existing land use or condition of the 7.7/ at the time of this application
n
(residential, undeveloped, etc) ��s�c�oN
6 Property size (acres)`
7 Lake/ river/ ocean adjacent to property 7-A -- e
8 Describe proposed work (include iscussion as to how hard _Wing of shoreline has been
avoided, or why it is y ece sary) � it e' e. 4.,1 fp
eEl� 01-4 ILe ,r-os,10_n roH- c;�� �� C ��e �c*uveSV
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 poq)ak level/ Normal Water Level in square feet or acres
So e ;lp 1
11 Total amount of disturbance (including all clearing, back fill, excavation, rip rap, "retaining
walls, etc ) above the normal pool lake le�YZIVV_-� Normal Water Level Z1, '5�'ln eet land -ward in
square feet or acres 04-80 11nec.�- ��S l Z k/Cf, d
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) / °n/rnvr- / ypoh fJcc
6j L GU h T /.1 4 CU ero_cv. '+ 'o-10 S G rG 1'`J�i
ViiWIM,
Owner/ gent'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 / 1 Page 2 of-3
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Full Pond/
Normal Water Level
i•
Shoreline i• i• ' '
La ke
(At Full Pond/ Normal Water Level)
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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
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See- �! C ✓ �e S
lre e,
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FORM: SSGP 10 -2013^ �n`f 4ire Page 3 of 3

FD 112 "PIPE FD DISK
s LAKE GLENVILLE
1 ��gBR S �S�segStc.
SET 1n' ROD
FD DISK
n �oi FD 112 "PIPE
r ` 1843 54Ip• o
Y `
FOUND PIPES OR RODS AT ` FD DISK
CORNERS N LOT,
NOT ,4 BOUN STHRVIS IS
DARY UEY,
BOUNDARY SURVEY BY r SO'�
W EDWARD HALL, 4115198, I z
CAB 61,SL.116
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SET�NAIL IN CONC V /
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SET 112 \ hr
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FD 1/2'PIPE /
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NAIL IN
CORNER
POST, 5 55'
NW OF LINE
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1, JOHN W, JURSS, CERTIFY THAT THIS WORK EXTENDED o
WAS DONE UNDER MY SUPERWISION; 2/12/0/
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HOUSE LAYOUT
Bearing Distance
L1
N 45 °21'01' W
1500,
L2
N 45 °21'01" W
1900,
L5
N 44 °38'59" E
24 75'
L'6
S 45 °21'01" E
16 00'
L7
N,44'38'59- E
3 00'
L8
S 45'21'01° E
19'00'
L9
S 44'38'59" W
3 00'
L10
S 45 °21'01" E
16 00'
L11
S 44'38'59" W
24 75'
L12
S 44'38'59" W
7 25'
L13
N 45'21'01" W
967
L14
N 44'38'59" E
7 25'
LIS
N 45'21'01" W
633'
0 REYLSED
FD 1127ROD LAYOLTSURYEY
PREPAREDTOR'
JOHN BAREHAM -OWNER
CHARLES HAGER -BUILDER
LOT 9, UNIT II', TAHALA SHORES

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