20140889 Ver 1_Shoreline Stabilization_20140815

State of North Carolina
2 0 1 4 0 8
epartment of E nrAent and Natural Resources
p i i i of�f�1(ater Resources
lJ U
15A NCAC 02H .0500 — Water Quality Certificaibtr�hoce�e Stabilization
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
Raleigh, NC 27699 -1650
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: S -rev C_ (-ig 1 A"i
Mailing Address: 12qZo (2,D
Cz'u- ,vs NG Z703
E-CEIVE
AUG 1 5 2014
Telephone Number: Fax Number:
E -mail Address: -°V. ic.t A a s rc w 6.f .-fie 7'G . (• 41
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 /docs /regulatory /reedocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: (' ?)C " -�o r.P 2ecvcl � IRc- e`
Company Affiliation: C
Mailing Address:
Telephone Number: -70Q- &&o -r,")) I Fax Number: `76 U - Co (p) 5q
E -mail Address: CbC I ae. -�
Person to receive the Certification Approval: Cti;D �c-�t -5
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 of the property (where work is to be conducted)
County: IMeck e AK) r eX Nearest Town: Cornet. uS . N�
Subdivision name or site address (include phase /lot number): 1.44 , 4-ona ,
Directions to site - please include road names and numbers, landmarks, etc.: 1-71 N o +o
i2im Iyf-+- an +o (In4a 6a Aoe, pa 1.5m;IQS a^J (Dear-Zor4o
n n� a.rri %Ic- rx+ 18 C4 aC) pant -
Q� I-1. Le.4-
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): des: den 1
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): -(o 54-abM 7Q <,} naJ;ne - o C` uen4-
2iJ05� an
9. Will work be conducted from land? E�r 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:
I' ,x To
11. Totai'�mount 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:
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
r
50 feet landward to be impacted (number of trees, for instance):
Owner /Agent's Signature [15A NCAC 02H .0502(f)l
Z
Date
`Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10 -2013 Page 2 of 3

Nora
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

I
give
CBC Stone and Recycle, LLC. /Natural Green
Scapes, LLC authorization to obtain the
necessary information for stabilization and
dredge permits.
I agree:
Date: �7/ z //

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