20140913 Ver 1_Shoreline Stabilization_20140822

2 0 1 4 0 9 1 3 state of North Carolina
Department of Environment and Natural Resources
D Division of Water Resources
Division of Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
r )OQivf; SSGP 10 -2013
Shoreline Stabilization Application Form V �
Four copies of the application (including attachments) and the application fee should be sent to:
Division of dilater Resources
RECEIVED
401 & Buffer Permitting Unit
1650 Mail Service Center
AUG 2 2 2094
Raleigh, NC 27699 -1650
DENR -LAND QUALITY
STORMWATER PERMITTING
I. Applicant Information [15A NCAC 02H .0502(ajl
1. Owner 1n rmation
Name: 1't? ZZ
Mailing Address:
t?r3 r 6,26- a x-03 /
Telephone Number: 7_ c�/ �Tn,� ��33 Fax Number: 76z/ E&LE /a 17
E -mail Address: j &- I f, � ch Ar,,,, I �'e C, �, \
NJ 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 1dacslregulatory /regdocs /Permits /SAMPLE AGFNT AUTW
ORIZATION FORPll.odf) m_gt be attached if the Agent has signed this application form.
Name: 0_h. n ac
Company Affiliation:
Mailing Address:
Telephone Number: tJU oleo 5111 Fax Number: 76 C/ &tat) 59 /e o1
E -mail Address: 0-be S, -/ -Lw a ([�np
Person to receive the Certification Approval:
Project Information LISA 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: k ► )r-m Nearest Town:
Subdivision name or site address (include phase /lot number):
36-%j 3)(a , - $D• 93786rp
Directions to site - please include road names and numbers, landmarks, etc.: 5--7-7 Soy 1\
ern orn�Vo W Oe-V of y 3bo A � p ixi M�tm Q
L n` . 9 n
�� � [�/1t� �'El le
0/Itlo f'1'1�Ilv�i n and 154- esn-to
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): _ e S JC e)tnJ
6. Property size (acres): D , -7 (4 of t f e S
7. Lake/ river/ ocean adjacent to property: _ _ d n rma:n
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): -�n S,tr,bg -j (; z e sbn& .�
)C- l" r P ro S ,` c--)rn
9. Will work be conducted from land? Eg,-- 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:
1501 x / '
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: ) 60 3'
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):
Owner /Agent's Signature* [15A NCA H .0502 f Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10 -2013 Page 2 of 3

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Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ftx 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
I 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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16700 Tinker PI
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