20141275 Ver 1_Shoreline Stabilization_20141210

2 0 1 4 1 2 7 5 State of North Carolina
Department of Environment and Natural Resources
DWR T �D� in 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 apF 1 )`igr>eF�c!!�t t
to: � o � 8 L
Division of Water Resources 1 0 2014
401 &Buffer Permitting Unit
DENT; R RESOURCES
1617 Mail Service Center 401 & BUFFER PERMITTING
Raleigh, NC 27699 -1617
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner I
Name:
Mailing
Telephone Number:
E -mail Address:
2. Agent/ Contact Person Information
Fax Number:
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http• / /yvww saw usace army.mil/Portals/59/docslregulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM. df)must be i �ched if the Agent has signed this application form.
Name: miler
Company Affiliation: LIAXtSi CtDt_l
Mailing Address: IbE'n w
Wy11(�d AJG ;I-Sl ZY
Telephone Number: rloy- 0,31 - iv O Y Fax Number:
E -mail Address: ,Iby; (d 4u, (4 wiadis-k-eam , r1L-
Person to receive the Certification Approval:
II. Project Information [15A NCAC 02H .0502(a) & (b)1
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 location5b
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) j
County: a, I W Nearest Town:
Subdivision name or si a address (include phase /lot number):
-1rIE0 A ry' 1� o I i . �./
Directions to site - please includd road names and numbers, landmarks, etc.:
RC+ T �0 7A i �L "'��i7� C� �,l/ 1 I T`'
Y�-
Latitude (in decimal degrees) Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): R—, % -L c L= '4
6. Property size (acres): L C,-- c_ rte- e S
7. Lake/ river/ ocean adjacent to property: 4: kc
S. Describe proposed work (include discussion as to how hardening of s oreline has been
avoided, or why it is necessary): >Pjp �� -L Ike"L 112 c% '�'��
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:
D
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: H lv o 5 c, Tf"
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to be impacted (num er of trees, for instance): 4 RCE�- <,
4
- �0,j c= G'
Owner /Agent's Signatur [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

Lake
(At Full Pond /Normal Water Level)
-ro t" l :T:kV.\ fe' + `? z 6-) F--
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

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO.
STREET ADDRESS: 5-y / Wac� u r "
Norwoj 61C -
Please print:
Property Owner:
Property Owner:
PARCEL ID: ( S7 3 a (0 7 7 /
The undersigned, registered property owners of the above noted property, do hereby authorize
190 d a F IQit. of L k) S+GLC. chy S
(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:
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
� J
Aut orized Signature Authorized Signature
Date: �Y Date:
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