20141104 Ver 1_Shoreline Stabilization_20141020

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s State of North Carolina
DWR 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
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 u �S
2
I. Applicant Information ['15A NCAC 02H .0502(a)] OCT oz 014
1. Owner Information DAN& BU FER E SOIJ CES
Name: Jacob Debelak rr G
Mailing Address: 524 Stonewater Bay Ln
Mount Holly, NC 28120
Telephone Number: 602 - 541 -2832 Fax Number:
E -mail Address: jpdebelak hotmaii.com
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.arm -y.niii/ Portals /5y% dots /regulatory /regdocs /Peri-nits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: Vision Scape Group
Company Affiliation: Landscaper
Mailing Address: P.O. BOX 4857
Rock Hill, S.C. 29732
Telephone Number: 803 - 984 -1099 Fax Number:
E -mail Address: [e-mail]
Person to receive the Certification Approval: Kyzer Cauthen
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: 55GP 10 -2013 Page 1 of 4

s '
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 wotk'is to,be conducted)
County: Gaston,County Nearest Town: Mount Holly
Subdivision name or site address (include phase /lot number):
Stone Water Subdivision LOT # 22
Directions to site - please include road' names and numbers, landmarks, etc.: Turn left
off EXIT 16,on 485 onto NC -16 /Brookshire Blvd. Turn right onto Horseshoe Bend Beach Rd.
Go 1.0 miles. Take 3rd right onto Stonewater Bay. Home sits in cul -da -sac.
Latitude (in decimal degrees) 35.354604 Longitude ( decmal degrees) _
80.966767
5'. Describe the existing land ,use or condition of the,,site, at the time of this application
(residential, undeveloped, etc.): Residential
6, Property size (acres): 0:95 acres
7. Lake/ river/ ocean adjacent to property: Mount Island Lake
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided', orwhy it is, necessary): Very small retamirfgwall and'two.(2) sections of rip. rap
will betused to help stabilize shore line
9. Will work be conducted from land? © From water? ❑
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc')
belowthe normal pool lake level/ Normal Water Level m square feet or acres:
No disturbance below the normal pool lake level /water level.,
11. Total amount oftdisturbance (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:_ 2,020 square feet- Includes 2 sections of rip rap -1 section of retaining
wall
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): A lot,of roots showing
FORM_ SSGP,10 -2013 Page 2 of 4

and erosion. Needing to remove 13 trees due to fallen or leaning
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Owner /A n 's Signature* [15A NCAC 02H .050_ 2(f)] Date
Agent's sig Lure is valid only if an authorization letter from the owner is provided.
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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 Fond/ 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
FORM: SSGP 10 -2013 Page 3 of 4

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