20221562 Ver 1_Shoreline Stabilization_20221109

Water Resources
ENVIRONMENTAL CU LITV
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 02-2017
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee shou
If sending via US Postal Service
Karen Higgins
DWR — 401 & Buffer Permitting Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
A. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name:
Mailing Address:
be sent to:
If sending via delivery service (UPS, FedEx, etc.)
Karen Higgins
DWR — 401 & Buffer Permitting Branch
512 N. Salisbury Street
Raleigh, NC 27604
J ck 5c4ii Lac_
3/ o /0,,LtAi bt fr-
Y X5boa /ilc 273N3
Telephone Number: 33b ZL7 2Z27-Fax Number:
E-mail Address: SCE e i°VI Ce_114-)IcV56,1e_5,6°,41
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter must be attached if the Agent has
signed this application form. (A form can be downloaded here:
http://www.saw.usace.army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
r95-6,-)
ItSc ( &ci6 i c (f.-�` >; d
Ba, ,'L- 2-75c
IN 7 -20-SSZ3 Fax Number:
rnI l)Sc� ,J s, .
B. 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, buildings, retaining walls, docks, impervious surfaces, 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.
FORM: SSGP 02-2017 Page 1 of 3

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: S`'l"` Nearest Town: ` c`'c
(o I c\k2
Lake/ river/ ocean adjacent to property: N y
Property size (acres): / s C O Of.3'
Subdivision naL � or site address (incl�d a phase/lot number): L
—ILL Rarb-i/
Directions to site - please include road n mes and numbers. landmarks, etc.:
1 U k:t— 5 1, tL) (- 1 c- 1 Cn sA y /c,� L l%, ✓�
u ✓�, I �f f- Cin (G I/,' , Iy
i Q C� ( Ct , O', , _ r� 4 i l k) i oGU b tt k.1 d
V-0Lo.ls5 pocult-
Latitude (in decimal degrees) 3 (:e 2 c6' aeLongitude (decimal degrees) .-- '7 q o q 03.
5. Describe the existing land use or condition of the sit at the time of this application
(residential, undeveloped, etc.): O ()Cie [ L� 1
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is n\ec ssary):
,,0•i( f�;pICU (LP ap`-
r
From water? ❑ -erosion
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (in Iudin all excavation{ backfill, rip rap, retaining walls, etc.) in square feet:
h-C-->r' X (Py
Temporaryy impacts in square feet:
7. Will work be conducted from land?
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanen impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
3 � X. (P t q, S7
Temporary impacts (temporary clearing, construction corridor) in square feet:
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50
feet landward to Ede impacted (number of trees, for instance):
U0()(3 C
FORM: SSGP 02-2017 Page 2 of 5

11. Signatu e
/
7/
Owner/Agent's Signature* [15A NCAC 02H .0502(f)l Date
*Agent's signature is valid only if an authorization letter from the owner is provided.
12. Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
La ke
(At Full Pond/ Normal Water Level)
Full Pond/ Normal Water Level
a
Shoreline
FORM: SSGP 02-2017
Page 3 of 5

)44+ ) L'-tr- 0'01-
La ke
(At Full Pond/ Normal Water Level
Side View
c
0
<(7)(--k(1)\(),
-)
Full Pond/ Normal Water Level
7horerne —
2 ft.z 150 ft
additional clearing
If necessary
E
Plan View
Lake
(At Fug Pond/Norrnal Water Level) Existing Dock
/30ftz7ft
�aorr�ar���o���rar..
��1��a•14.0" raz�1
.ii1a►'�� Riprap
•..**� Ki
ir
ow w ve
AMPL
3 ftt 150ft
Below full pond/ NWL
Imo
4 ftz 150 ft
Above full pond/ NM
E
FORM: SSGP 02-2017
Page 4 of 5

3 ft. below full pond water level 4 ft. above full pond water level
2 ft. additional clearing
*if necessary
Existing bank
10 ft. bank
height
Side View
I
FORM: SSGP 02-2017 Page 5 of 5

7/22/22, 9:20 AM
Caswell County NC WebGIS
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818 BIG LIPPE(
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, '3 LITTLE DIPPER DR
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90 LITTLE'DIFPER DR
66 LITTLEDIPPER DR
DIPPER DR7.�.,:+ LE DIPI ER R
8 LITTLE DIPPER DR
POLARIS ! 1
17 POLARIS PT
205 POLARIS PT
209 POLARIS PT
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NCRT° CAiic ..: A, ' RSON COUNTY
!;.Irt. Cate-, Jr. bell:: duly sworn
and ^-
says that he has compiled the aboveplat :romr. e
actual survey by h:W ode and that it is correct At
to the best of his 'snowledge and belief. Thin the
23rd day o: May, 1966. r
it
Sworn to and subscribed before r..e, thi„ the
23rc day. of May, 1966.
O\ .gyptaty Clere super_or3h t..
\`.. ...ion Courty, Kort - c\ •i5,
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SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. lam' /�
PLAN NO. PARCEL ID: ea u COUi:
STREET ADDRESS.;' CI q2
cie1 4/c 273 /3
Please print: f, h
t
Property Owner: V �rCG - f L c 1
C.
Property Owner: (W ,{ ( L o V,
The undersigned, registered property owners of the above noted property, do hereby authorize
ctoi its , of
(Contractor f'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):
3,8 Ieh,�ot,J�i �z((ac� G��n� g Z73 --/3
Telephone: �3 _ z %— 2 2 2 Z
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
0)ciDK
--"/C-- Authorized S. natureW tA&e'
�Y�l
Authorized, nature
Date: 7 Lis ZG�z_ '".1 / 8 21.-
Date:7/0
U13(1009