20141091 Ver 1_Shoreline Stabilization_20141015

2 0 1 4 1 0 9 1 State of North Carolina
Department of Environment and Natural Resources
DWR
- Division of Water Resources
i
15A NCAC 02H .0500 _ ateW r Quality Certification, Shoreline Stabilization
Division of Witter Resources 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
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
OCT 1 5 2014
DENR - WATER RESOURCES
401 & BUFFER PERMITTING
Name: D
Mailing Address: 1 l c A v
AJ (f a� I
Telephone Number: 5/6 -SS 1) Fax Number: 334 - 3
E -mail Address: 1)0.v 1, 0 2) e ieay-t-V<� clr
2. Agent/ Contact Person Information T
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:
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 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: f�'P6�U� Nearest Town: SPjuoye,
Subdivision name or site address (include phase /lot number):
Directions to site - please include r ad names and numbers, landmarks, etc..
Describe the existing land use or condition oflthe site at the time of this application
(residential, undeveloped, etc.):
6. Property size (acres):
CU.. / e v c r--f
7. Lake/ river/ ocean adjacent to property: 9 CU Ike
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): ow �.,1 ��) cu C,k( A0,; V
(,�� � 5 0�►�� P}wov[�� AIUV? oVS�A S,
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:
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: 360 X ]
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): 1® t F' S
� l
Owner /Agent's Signature} [15A NCAC 02H .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

Full Pond/ 3 60
Norma I
Shoreline
r W
.Avtl
La ke
(At Full Pond /Normal Water Level)
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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

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