20140973 Ver 1_Shoreline Stabilization_20140911

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2 0 1 O PA t� of North Carolina
DWR 4 9 7 3 Department oTEmriroa rneM and Natural Resources
Division of Water Resources
Division of Water Resources iSA NCAC 02H .0500 - Water Quality Certification, Shoreline Stabilization
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
RECEIVED
401 & Buffer Permitting Unit
SEP 11
1650 Mail Service Center
Zp�y
Raleigh, NC 27699 -1650
DENR -LAND QUALITY
STORMI'VATER PERMITTING
1. Applicant Information 11SA NCAC 02H .0502(a))
Owner Information r
Name:
Mailing Address: Nt 0 Avg C\ —I
Telephone Number: `t01 -Z��- �3�`� Fax Number:
E -mail Address: c7 011A . C ILI �^
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 /regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: 13 o 13 M A-K Ti
Company Affiliation
Mailing Address:
a ENT-_I _ {3 0 t3S b 0 UCS/ Vl-w /--c L- C 0
P, 0 3 nu r 30q `
6-C- Ir N 1f c lc. -, N, c. 2 8 7 3 io
Telephone Number: BZk -- 22.6 - Z 09 7 Fax Number: 2 L O
E -mail Address: PoPP°'_ do05 6 & ad� 1 • G°
Person to receive the Certification Approval: 0 01-H
11. Project Information 115A NCAC 02H .OS02(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

,a.
etc.), rip rap, excavation or dredging below Full Pond/ Normal Water Level efevatfons;
and construction access cord0ors. You maywuse,the diagram provided at-the end of this,
application form.
I Attach a photograph of the shoreline/ buffer proposed to be,stabilited. (include a scale
ofsome. sort -a"yard stick; shovel handle, etc.)
4. Location of the property'(wherework'isto be�conducted)
County: � - ��=s�� (dearest Town: , •��Q-
Subdivision, name orsiteaddress- (includephase /lotnumber):
Directlons to site ;please include road namestand numbers, landmarks,;etc.., ,
(0 7 t Al WWL
S°CK00, L
5. Describe,the,eklsting land use, or condition of the 40A the time of thi&application
(residential, undeveloped, etc.): C- SI "i"ti;.
6. Property Mzed(acres): L C)
7. Lake/ river / ocean adjacent to property: L�$ -1•c GiJ IR Ltd.
g. Describeproposed work (include,discussiou as to how`hardeninghof shorellne,has.been
avoided, or why Iris necessary); T`D -STA6M II--C Sf$'QgE, I -foes. F;"I+r^
F *i> gjez S i DA W rT 4 STS STaw c 4 P.1' 0 R&e
9. WillwuorkIbe conducted °ftm land! E] From waterl
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:
ll.'Total,amount of disturbance (including ate- learing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal poolflake leirel %'Formal (Mater Level and "50 feet land- wardain
Isquare4eet & acres: S Q \ t
12-. Pleawdescribe thewegettation abovethe -hormal pool,lake level/ Normal Water Level and
50'feet,landward to,be impacted °(number oftrees, for "instance): a NLY Sot3&,
S Pao , -, _ .»R CA�lA u V_< -- - -
rJ I dkca Vfl,-1&J6A- I F � a I?- -Zo/ y
Owner /Agent's Signature 41- SA'NCAC,02H .0 f 1 Date
vA a f ,hatizarlomletter from dwownter is provided.
FORM: SSGP 10 -2013
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SEP 11 2v14
DENR -LAND QUALITY
ST MITTING
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