20141172 Ver 1_Shoreline Stabilization_20141110

2 0 1 4 1 1 7 State of North Carolina
epartment 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
Three copies of the application (including attachments) and the application fee should be sent
to:
II.
1
2
Division of Water Resources 9 �/ i
401 & Buffer Permitting Unit �VI
1617 Mail Service Center 1 0 2014
Raleigh, NC 27699 -1617 INOV
Applicant Information [.?SA IVCAC: 02,9.050,,_(a)]
I. Owner Information
Name: Al ii-i a AL'
Mailing Address:
2. �6 7 r
Telephone Number: 3.��94L Fax Number:
E-mail Address: �a-73
2. Agent/ Contact Person I formation
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
_ ? .US8ce.ari71'V.CTIfI PnCiai /l/59jciocs re ulato re docslPermits %SAMPLE AGENT AUTH
oRIZATION r E_0R�f) must be attached if the Agent has signed this application form. ��-
Name: moo, 0 n dl M
Company Affiliation: _ R� t@ /Yi ®Se-
Mailing Address: 1''1 TQ
c 2 8'6x9
Telephone Number:
E -mail Address:
Person to receive the
761 2 /3#97 Fax Number: 'Ka-Jr alf
ion Approval:
Project Information 15A NCAC 02H .0502 -a & (b)
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.
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: Nearest Town: T
Subdivision name or site address (include phase /lot number):
°' _ / f A / s / / _.i
Direcfions,to site - ,please include road names and numbers, landmarks, etc.: _
Latitude (in dec/mai degrees )lLirjj Longitude (decimal degrees) .16,
5. Describe the existing land use or condition of the site at the time of this/ application
(residential, undeveloped, etc.): ' '/_
/. A U1lde�/ i'eDr9d _
6. Property size (acres):.
7. Lake/ river/ ocean adjacent, to property:
8: Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 91- N%dA'. tJAJi_r► nf:A inR
'9. Wilf 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: a. ' Rap
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):
-�lll J�.f�l�' /�.e►o -ice /f Jr� �`i� /D AGk
k -
Oinlner ent's.Signature Printed Name Date
CAS' 02H
Agent's signature is -valid only if an, authorization letter from the,owner is provided.
FORM. SSGP 10 -2013
Page 2 of °3

Lake
(At Full Pond /Normal Water Level)
Full.Pond/
Normal Water Level KIP
e �
. k
Shorelin- s,�_— a�4y�-
T
to
V
TITIAd-.5 70 *keec
ill AAMh6
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Please approximately sketch the following nformation on this lan
item, such as loft x loo ft) *: g P (provide dimensions for each
1.. All proposed vegetation clearing b ®ut� .�o ( ,Z, � � ° �(Se - S.
g t9 ;,5 T --ees
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. Lo f any - excavation or dredging below the'Full Pond/ Normal, Water Level' elevation
6. Location of construction access corridors �� �� �lf' i� ���� �iP Q_
���l � T -A&K P% (z, / °
Rif RAP toi/I ic.,,Pme IA 6y w
FORM: SSGP 10 -2013
Page 3 of'3

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AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. �, PLAN'NO.,' PARCEL ID:
IM
STREET ADDRESS:
Please print:
s
Property Owner:
Property Owner:
The undersigned, registered property owners of the,above noted property, do hereby authorize
,Olyeej ,of 1
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for °the processing, issuance and acceptance.of
this permit,or certification and any and all standard ,and 'special conditions attached.
Property Owner's Address (if different than property above):
Telephone: _ 3,3z-, GU a 1Tc?j6,,o
We hereby certify the above - information submitted in,this application-is true and accurate to the
best of our knowledge.
Authorize ignature Auth rize Signature
a
Date: Date: ;

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ALICIA FIELDS raaocr,n 1 JOHN DARDENJR,,PE ENGINEcRING'SENCES
LOT I34 343 WINDEMEREISLE DR i
IRFDi COUNTY NC D"m W f A4F`A'
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