20141006 Ver 1_Shoreline Stabilization_20140929

2 0 1 4 1 0 0 6
State of North Carolina
DWR - Department of Environment and Natural Resources
Division of Water Resources
Dlvlslon of Water Resources ' %15 fWAC 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
401 & Buffer Permitting Unit rILE CO
1617 Mail Service Center
Raleigh, NC 27699 -1617
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: Ear 1
Mailing Address:
SEP 2 2
2014 10,
SOU
CDENR •WAER TRE401 R RIrrr RES
40 AoR;-
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Telephone Number: -- Fax Number:
E -mail Address: ^ sS�ec —'i , oaf
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
ORIZAT ION FORM.pdd ) /must be attached if the Agent has signed this application form.
Name: Kip Y�cer �17�.[,[G Gh4
Company Affiliation:
Mailing Address:
I o -oy GJl r how bak d _
No r,UDor� . NC xu,2
Telephone Number: 6q- q3 '9-6'(PW Fax Number:
E-mail Address: fbUa ld'fc(a lA.ii/VJSfY'P_af1 i
Person to receive the Certification Approval: lZOlo�rf
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 is to be conducted)
County: _ 1 A ii1 -� ul Nearest Town:
Subdivision name or site address (include phase /lot number): TRR° g u.` 13c"
Directions to site - please include road names and numbers, landmarks, etc.:
110 y 5' -) -tn M©Pez.►or-"-( -h, _TA4J, 4,,J /",:*I ad �01
-10 b Oi4,r _ fo ZX_ � �
Latitude (in decimal degrees) _3 SF:. -q�5 Longitude (decimal degrees) ` o %, tq
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.) 5 C cQ, Win/ + i c.,
6. Property size (acres): I& o,. C� 2 c S
7. Lake/ river/ ocean adjacent to property: �
8. Describe proposed work (include discussion as to how hardening of s oreline has been
avoided, or why it is necessary): P-OMo V6 014,,,, x, d
S G' A ]s+ li. l % a►1',P
Z
. 1 s
9. Will work be conductedirom 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:
3 Y 1 0 0 3oc, Sy Flfz i�
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: 3 X ° ° 3 o 7'
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): ,ONE lbo_i a
U a Fr X IR e- e- 10 J0 6- -&-q
Owner /Agent's Signature
Printed Name
11AoM, -� ?11-11-q
[15A NCAC 02H .0502(f))
Agent's signature is valid only if an authorization letter from the owner is provided.
Date
-r
FORM.,SSGP 10 -2013 Page 2 of 3

Full Pon /
Normal Wat r Lev EM Em
Shore ne
Lake
(At Full Pond/ Normal Water level)
3 Y 1'66
3 � 1ea
4 NEW am
L1113Rip
p, Ap
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

PROPEKFY LEGAL :
for -NO. PLAN NO. PARCM V.
rctmIti l bai 6rd e-
n i r� + -`
Piewelprm
Property Owner:
The urn, registered property owns of the above robed prop", do hereby authorize
P rf i Lam, �s, Casa c rs
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to act of my behaif and wm an ad= necessary %r the pig, imuanae and acDBPtmtm Of
thts pern* or cardflaom and any and all starxiard and qMW axddm armed.
pr y 0 w ni es Ad &m (if Wo a it titan arty Ame):
T
V" hereby raft the abwe hftnullan aftftW In this_ appkatim Is We and MUSIC W the
best of ow ice.
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