20141155 Ver 1_Shoreline Stabilization_20141103

2 0 1 4 1 1 5 5
State of North Carolina
DWR Department of Environment and Natural Resources
Division of Water Resources
Division of Water Resources 1SA NCAC 02H .0500 - Water Quality Certification, Shoreline Stabilization
FORM- SSGP 10 -2013
Shoreline Stabilization Application Form PAN
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
1 Owner Information
Name
Mailing
MM
Telephone Number 7 ?40 - 3954-Y7,00 Fax Number
E -mail Address iUJ /LSoN -/cC- 4-"0 /0
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 /reeulatory /reedocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM pd f) must be attached if tjhe Agent has signed this application form.
Name BIER
Company Aff iliation
Mailing Address
Telephone Number 7f0 3f- Y 7h40 Fax Number
E -mail Address eiIVlLgoA J &'5fsPr7ccJIr✓eC.a4t
Person to receive the Certification Approval -Je"Y L "LS.6A/
II. Project Information [15A NCAC 02H 0502(a) & (b)]
y/1 Attach a vicinity map (i a 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. MAC -0IJ Nearest Town F&P To #j . AQ uDy1/r
Subdivision name or site address (include phase /lot number)
9'? Z LAKES Oa.E DRiLI'+ , 70P7W /V G 28-791
Directions to site - please include road names and numbers, landmarks, etc . ol:�Qo'w
la/AyAR RoAo 0* 13 1o) TAKE L/OLGYR24,E ;Ra AT
6AAmwALA Mofl44 yas Lamm oso a O, h� /yllLrS3 Lehr api
1_oWe6Ho2E 1 X. Fd2 / m/cF 7'o 9, ?Z. L,/l.Ce".sfloQE.
Latitude (in decimal degrees) 35. 1 f¢-C4 } Longitude (decimal degrees)
5 Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc) 9C51o&-7LrI-1AL-, yoMESI71f-
6 Property size (acres) /.6) AG,ees 4-
7 cake/ river/ ocean adjacent to property LA-CO /11AXrrAHA LA
8 Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary) To STASALI-Z E SHo2EGiNE h>171/
. P-Y STACK RIP kAP DUF Ta 6CoSIo of OF 6.#o2.6
9 Will work be conducted from land? [V]' 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
3990 sQ A'T
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- 30D 3Q FT.
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): 3 _V*W4tt-
TQ.g-i�S 8't- le'), "✓ 01AME—leR., "If-rW we;eY L /7`lZC
-;tqX VZ0,9 2Y To 8iW R,0446 ✓Ep
D�r.OLMZ 27 Zol
KW'n*
er /Ag is Signature [15A NCAC 02H 0502(f)l Date
Agent's s nature is valid only if an authorization letter from the owner is provided
FORM SSGP 10 -2013 Page 2 of 3

Vicinity Map for 982 Lakeshore Drive, Wilson Shoreline stabalization
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via Wayah Rd ( #1310)
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