20140859 Ver 1_Shoreline Stabilization_20140811

2 1 4 0 8 5 9 State of North Carolina
�'11D Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H.0500 — Water Quality f- tj efine Stabilization
Division of Water Resources
FO SSG P 10 -2013
Shoreline Stabilization Application Form
Four copies of the application (including attachments) and the application fee should be sent to:
1
is
Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650
Applicant Information [15A NCAC 02H .0502(a)]
Owner Information
Name:
Mailing Address: 1ZZ kQi1� Lc, VC_ CJ�` .
moo "SVille, N(_ Z9f 11f'
owllQ
auc I 1 20
14
i
D iJf2 - iVA _ AL J
Telephone Number: 9-0 (al Fax Number:
E -mail Address: K&DA -SA S A-C t—
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.miI /Portals /59 /dots /regulatory /regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: �%✓%/ruI /4c1�Ic'�`
Company Affiliation: 71 d,"6"e' c fr '20 q '
Mailing Address:
Telephone Number: 709' -(o 3 - 397$ Fax Number: ?may —(vG-s 2�-
E -mail Address: /."6_4 f 'le, •_ CA? dy 4'1� R"/- ' .
Person to receive the Certification Approval: '0hc "1 r4l.,iel'-
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

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 oftluepro y ( ere work is to be conducted)
County: _ 4,k _ Nearest Town: M 0 0 f,es\J I'll �
ubdivissioln name or site address (include phase /lot number):
pN � S C) / v L- c\ rV i� i ev
Directions to site - please include road names and n 6
63._7A vv �y S JV v[ R-6 � > +-
. R_ 1
C_:
rs, landmarks, etc.:
C c,.\✓A-S 6 4-Ck
5. Describe the existing land use or condition of °the site at theAti
(residentia'I, undeveloped, etc.): K S '1 di /\, �, t
6. Property size (acres):
016
of this�application
7. Lake/ river/ ocean adjacent to property: L. -A-Ke Q' &.I-,,V\ A-A
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is nec ssary): O i J� 42X1`3 7�t/t1 YI
9. Will work be conducted from land? IXI 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:
Z$= 2,4,-Z& 40-r
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal
square feet or acres:
r Level and 50 feet land -ward in
12. Please describe the vegetation above the normal pool, lake level/ Normal Water Level and
.,5-dleet landward to be impacted (number of'trees, for instance): 44-V
e-
T 4 - -
Owner /Agent's Signature [15A NCAC 02H .0502(f)]
Date
Agent's signature is vand'only if an authorization letter from the owner is provided.
FORM: SSGP 10 -2013 Page 2 of 3

Full Pond/
Normal Water Level
SI
La ke
(At Full Pond / Normal Water Level)
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 -2013
Page 3 of 3

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