20141286 Ver 1_Shoreline Stabilization_20141213

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State of North Carolina
Department of Environment and Natural Resources
Division of water Resources
15A NCAC 02H USCG — water Quaht1 Certification, Shoreline Stabilization
L,I it o-� of tr;s FORM SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to,
[1 M 1� n
Division of Dilater Resources
401 &r Suffer Permitting Unit ID14 i
"ET1
1617 Mail Service Center
Raleigh, NC 27699 -1617 _WATERRESOURCES
F R ERMITTING
� L
I. Applicant Information [15A N AC 02H 0502
DENR - wAl ER RESOURC
1 Owner Information 401 &BUFFERPERMITV
Name W,a..Y
Mailing Address
Telephone Number S e- i 1515 Fax Nurnber
E-mail Address a'T r.1
2 Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here
It /ftiv,�� _ ,� �is�c� ar,7i �_n�il,�I' i �ls 59fclecs /�E �latorylreclucs /E cr,n�tsj5� iNPLc /?GEIJT AiETEI
ORIZATION FORM pdf) must be attached if the Agent has signed this application form
Name <
Company Affiliation
Mailing Address
Telephone Number 41A 3 <z)-17-3 Fax Number
E -mail Address .\s����v�� nrn
Person to receive the Certification Approval TY
II. Project Information [15A NCAC
1 Attach a vicinity map (i e street map) clearly showing the location of the property with
respect to focal 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 f

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 Attacti 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 ��<- (5`�t' "t Nearest Town �wttv-C..
Subdivision name or site address (include phase /lot number) L c44
Directions to site please include road names and numbers, landmarks, etc kle
C/
Latitude (,n dermal degrees) �S • % ?� Longitude (dearnai degrees) 'Y
Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc ) �'CS ,,� It
6 Property size (acres) y„)y
7 Lake/ river/ ocean adjacent to property _L1"C
8 Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary) tn54� It >c�
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9 Will work be conducted from land? ❑ From water? [�
10 Total amount of disturbance (including all excavation, backfill, rip rap, retaining wails, 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/ Not mal Water Level and 50 feet land -ward in
square feet or acres '7S :;�q P
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) S(Jvfwt )5 Afl-z-s
Owner /Agent's S gnature" [15A NCPC 01H 0502010 gate
Agent's signoture is volid only if on ourhorization letterfrorn the owner is provided
FORM SSGP 10 -2013 Page 2 of 3

Normal dater Level
St)oreline
t
La ke
1 (VQ ""laiW3t; -�P�:a
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

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