20140960 Ver 1_Shoreline Stabilization_20140909

2 0 1 4 0 9 6 State of North Carolina
Depa ent of Environment and Natural Resources
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 C 1
401 & Buffer Permitting Unit 1 Q a�l
1617 Mail Service Center
Raleigh, NC 27699 -1617
I. Applicant Information [15A NCAC 02H .0502(a)]
I. Owner Information
Name: 11,A14TT'
Mailing Address:
_7'0No '% LQ1&eE'4S0k*' -Da. .
CoeP"U&S , N L 2AzD1 t
Telephone Number: Fax Number:
E -mail Address: M�bC�c�.�p,r�1 @+�oal�vii.l�r�pV ISoQS . C, WV- ,
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 /reQUlatorV /ref?docs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: WEVe ,
Company Affiliation: —�D LAr4DSC4aP<LS, -r-ou c-
Mailing Address: (1-7 (l StStc CatMZi4V. —Q,p -
InlL ZA13�
Telephone Numbe( -1.0 -10- 1- S"q Fax Number: 04) -1210 - 0-143
E -mail Address: - 1-Di.AND4 -4n APES. &,A(44S Ar4DS0L t- Caw. _
Person to receive the Certification Approval: lCl-l_AEt.. Werrr;rz
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 of the property (where work is to be conducted)
County: Nearest Town: COR.nIEW'" s
Subdivision name or site address (include phase /lot number): EA4ka_" > Car E
Zo,) l
Directions to site - please include road names and numbers, landmarks, etc.: ''l I
-1'o G4'I`�►�" �4 iZo . �Egip W 65 'V44"5 C�tKnCi4 �o Qt ar,rit�
'p,EtKE� C ku a4r,u ac . Lr.Ft o..rro &+ Ee1.14 V e Si-r.. W01- u- (;k o.r (24 bar .
Latitude (in decimal degrees)
Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): %5,1 oeri-n r.*,
6. Property size (acres): t • 10 2 IJc, g cc
7. Lake/ river/ ocean adjacent to property: LAk-,y Non,%kp,J
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Vaz. o in4e, TnS1N4,s,.n0,4 o F Rop RAP IN"r4 ,
stto��.cr T• PaF,�-; Eao: o,.a axr4 s Srte�ku ��
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 pool lake level/ Normal Water Level in square feet or acres:
APO a% x . '2'%o SdL Alt Farr
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: AOP"X . '2,o o-o Sdus_A/LI F5
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):
vP --f&ES '3'
(?Nw19.8TJ
Ow er /Agent's ignature* [15A VCAC �QM4 0 ,,nwi )
Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10 -2013
Page 2 of 3

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. --A PLAN N0. JNA PARCEL ID: 00 110 c62%
STREET ADDRESS: 'L-04 15 CQ r%l St4ah.L .
Cae-r4g4AA4.5- , Pf C, V%03
Please print:
Property Owner: M AV- 5, �
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
s M 14, 404t- 4t- or 3'o L Arg P 5Cp Ft 5 1 —x4 c .
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
Telephond Ii 32-) y ?. -- I Vo 4
We hereby certify the above information submitted In this application is true and accurate to the
best of our knowledge.
Authorized Signature Authorized Signature
Date: - 1 (3,114— Date:

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