20140766 Ver 1_More Info Received_20140815

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4Xatural f North Carolina
Department of iro r�r Resources
DWR Division of Water Resources ---
Division of Water Resources 15A NCAC 02H .0500 — Water Quality 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 [15A NCAC 02H .0502(a))
Owner Information c�
Name: h�' PQt( 1-4X_)KA3,LL_
Mailing Address:
Telephone Number: Fax Number:
E -mail Address:
2. Agent/ Contact Person Information
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FAUG 1 5 2014
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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 /reRulatory /reRdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation: _Z L Fof c
Mailing Address: PO i�2)< I t9-I
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Telephone Number: 76+-gK 3 I P Fax Number:
E -mail Address: R&U- , �3�POPC i CO
Person to receive the Certification Approval: �4N'7- A-1) r
II. Project Information [15A NCAC 02H .0502(x) & (b)J
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- STAN I-Y Nearest Town, Nagwto p
Subdivision name or site address (include phase /lot number)-
Directions to site - please include road names and numbers, landmarks, etc F2)00
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Latitude (in decimal degrees) Longitude (decimal degrees)rr
5 Describe the existing land use or condition of the site at the time of this application
(residential, undevelope�d, /etc ). "90I'DON TIA L-
6. Property size (acres), .% f
7. Lake/ river/ ocean adjacent to property. LA14F RU,,M ►'
8 Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary). RtflACC PED ESI A LAAVP 0
9 Will work be conducted from land7;21*�' From water? Q
10 Total amount of disturbance (including all excavation, backfill, riip rap, retaining walls, etc )
below the normal pool lake level/ Normal Water Level in square, feet or acres.
,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, � EZSZ::> -5i F-p
12 Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to Ve impacted (number of trees, for instance): EXIST10 -- LAVJpJ
Owner /Agent's Signature* [15A NCAC 02H 0502(f)l Date
Agent's signature Is valid only if an aiuthornzotion letter from the owner is provided
FORM SSGP 10 -2013 Page 2 of 3

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FORM SSGP 10 -2013 Page 3 of 3