20141281 Ver 1_Shoreline Stabilization_20141212

En� State of North Carolina
'y 2 0 1 4 1 2 8 1 Department of�Env ent and Natural Resources
D WI
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: SSGP 10 -2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
1.
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699 -1617
Applicant Information [15A NCAC 02H .0502(a)]
Owner
Name:
Mailing
o GC 19 OUR
DEC 1 2 2014 `
DENR - WIaTi.Fi - <ES4URCES
MITTING
Telephone Number: Fax Number:
E -mail Address:
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/­­regulatory/`regdocs/­Permits/SAMPLE AGENT AUTH
ORIZATION FORM pd f) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E -mail Address:
Person to receive the Certification Approval:
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
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1.
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 pro erty (where work is to be conducted) /
County: GO, Nearest Town:
Subdivision n e or site ddre (include ha /lot number):
r%
Directions to site - please include road names ar�nur ers, landmarks, etc.:
Latitude (in decimal degrees) _.�, o72A�rZ%b Longi�ude (decimal degrees)— • eV2 9�
5. Describe the existing land use or condition of the si at -the tune of this application
(residential, undeveloped, etc.): c°S
6. Property size (acres): .
7. Lake/ river/ ocean adjacent to property: C
8. Describe proposed work (include discussion as to how hardenin of sh reline has been
avoided, or why it is necessary):
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 pater Lev I in square feet os 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 d 50 feet land -ward in
L e
square feet or acres: —
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and "
50 feet landward to bb pact umber ,of trees, for instance):
Wn4 KAgen't's Signature Printed Name Date
[15A CAC 0- L.0502(f)7
}Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10 -2013 Page 2 of 3

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1
Full Pond/
Normal Water Level
-r^Y SW`s Z.]Ki°Ei !-I'- ?.rte`_';€
Shoreline
La ke
(At Full Pond / Normal Water Level)
Y
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 f t) *:
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.
S. 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

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