20140939 Ver 1_More Info Received_20140919

State of North Carolina
DW'R Department 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 1 40 A 3 9
Z
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
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: r, 4
Mailing Address:
I a L V,
SEP 1 9 2014 ` I
C4Pdde
Telephone Number: 2 y Fax Number:
E -mail Address: ', 0 1 2 -e G o o C a
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.armV. 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:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E -mail Address:
Person to receive the Certification Approval:
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 3

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 into be conducted)
County: Oau' Son Nearest Town: L Px'fn A
Subdivision name or site address (include phase /lot number):
R
Directions to site , please include road names pnd numbers, landmarks, etc.:
l•".
Latitude (in decimal degrees) Longitude (decimal degrees)
Describe the existing
(residential, undevelc
6. Property size,(acres):
7. Lake/ river/ ocean adj
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
9. Will work be conducted from land ?,Er-- From water? ❑
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls; etc.)
below the nor l pool lake level/ Normal Water Level in square feet or acres:
01 c� b o _
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the norma'I pool la�e level/ Normal Water Level and 50 feet land -ward in
square4eet or acres:
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):
S 6 I
Own er /Agent's,Signature Printed Name Date
115A NCAC 02H .0502(f)1
*Agent's signature is valid only ij
FORM SSGP 10 -2013 i
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`an authorization letter from the owner is provided.
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Davidson County Map Output Page
Davidson County,GIS
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Parcel Number
06035DOOLOO 19
Land Units:
LT
Pin ld,:
67,1,0-04-50-8824
Deed Book:
1743 Pg: 1'143
F B LEE DEVELOPMENT CO INC
Owner:
1318 LEE iROAD
Deed Date:
11 01,2006
THOMASVILLENIC 27360-9434
Propert,v Address:
2340 RfVERVIEW,RD
Account Number:
9082682
Township:
06
Exempt Code:
Building Value:
t�
SO Other Building Value:
so
Land Value:
S 125.000 Marl,et Value:

y Davidson County Map Output Page
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avidson County GIS
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567009
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Page 1 of 2
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Parcel Number :
06035DOOL.0019
Land Units:
1,r
Pin Id,:
6710 -04 -50 -8824
Deed Book:
1743 Pg: 1143
F B LEE DEVELOPMENT CO INC
Owner :
1318 LEE ROAD
Deed Date:
11/01/2006
THOMASVILLE NC 27360 -9434
Property Address:
2'340,R'IVERVIEW'RD
Account Number:
9082682
Township:
06
Exempt Code:
Building Value:
SO Other Building Value;
SO
Land Value:
S 125,000 Market Value:
S "125.000
http: / /webgi s. co ,.davidson. nc.us /website /davidsongis /printpage.aspx
8/22/2014

FL
Norma
St
La ke
(At Full Pond/ N rrpal Water Level)
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Please approximately sketch the following i forma ion t is plan (provide dimensions ?r e
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

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