20141221 Ver 1_Shoreline Stabilization_20141125

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State of North Carolina
Department of Environment and Natural Resources
DWKDivision of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources N' FORM: SSGP 10 -2013
Shoreline Stabilization App icdtion 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
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: JLII , i
Mailing Address
196--21 t�oj iz VA
0J0Vrne1! � LS IsL Q903,
Telephone Number: %4. 5,- i53•r1g0n Fax Number: '104 5_-Y� ��JUO
E -mail Address: DQw\v kL- QC,BC� \/j t Q CoAk
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 /S9 /docs /regulatory /regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORlyl.pdf) must be attached if the Agent has signed this application form.
Name: �Y Mxrk
Company Affiliation: �.GL�C�� },ter c '�.c Div, I�rr ►� � SWA:f� C
Mailing Address: 1l5(� Pex�1, IZ�
IG LP
Telephone Number: 90q-5-213-9400 Fax Number: `10L�. &�?6 311 o0
E -mail Address: l.�h.ICAS'�(LncrX
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 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: O nr ^ l i u C
Subdivision name or site a ress (include phase /lot number):
Directions to site - please include road names and numbers, landmarks, etc.,: -
11 -to 1,112sk On l Al C� tQ A A J0a 74516-
Latitude (in decimal degrees) 3s• -�Sq Ly__S Longitude (decimal degrees) —& ®0 (1044
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): P`e si !y)b aA
6. Property size (acres): [ • 52
7. Lake/ river/ ocean adjacent.to property:2 NbrmQn
8 Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): aY1 %Qne-c
S�n�c�- xA -�o PPrI� Rnc1(,
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•
(DI X a2sI
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: % )< a35
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). K6yr YiQ�I
--� Printed Name Date
Owner /A ent's Signature
[15A NCAC 02H 0502(f)j
Agent's signature is valid only if an authorization letter from the owner is provided
Page 2 of 3
FORM SSGP 10 -2013

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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
Page 3 of 3
FORM SSGP' 10 -2013
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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
Page 3 of 3
FORM SSGP' 10 -2013

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