20221564 Ver 1_Shoreline Stabilization_20221109

Water Resources
ENVIRONMENTAL QUALITY
c9vao-1SC04
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 should be sent to:
If sending via US Postal Service If sending via delivery service (UPS, FedEx, etc.)
Karen Higgins Karen Higgins
DWR — 401 & Buffer Permitting Branch DWR — 401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information
1. Owner Information
Name:
Mailing Address:
[15A NCAC 02H .0502(a)]
e be/3 a Lever
0 (heAd ©w big°'(C T z
Otzt,)sixro l fC Zj Lf0
Telephone Number: 33 6 i07 1-22tFax Number:
E-mail Address: SLci it, IGJt@
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/dots/regulatorv/regdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
r{(i5ilv) 01;I15
050s b::(16.1c (ramk-- Kci
$AkcAi Ak Z 750
Telephone Number: I7ZGi 5523 Fax Number:
/11 IIU n 719&y/'101, i• C.4,-y)
E-mail Address:
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: Nearest Town: R?7 /VC_,
Lake/ river/ ocean adjacent to property: `4,t j CC; La
Property size (acres): c $1 C c✓L-
Subdivision name or site address (include phase/lot number): Qj/ ' -{Ch m7�- j3
J Fluid 1---Pa ici S
Directions to site - please includeroad names and numbers, landmarks, etc.:
Frb rn Po(bn rqj N(- -fi�.l� r2 1--t u) y J '7 N -1-0 c, (-) La ,
crass ?) b r,i f � d � 1--F CCU, Tc rA I e -P-f- o n -�j
( (t.1" br , 0 60 %�'1 and `fr1 {C a r i h v-1: 60
P'r � Iv rY) 12 ld-- Lc)f ,.S a-- +he end
cg► � �
Latitude (in decimal degrees) 36,G26 3&,q 'Longitude (decimal degrees) - 79 C7 4 Oct, ,5
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): L C"CLGd)
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
O-0Jd. Li 1 Qc np rcip 6_0609 —hcriCJ
7. Will work be conducted from land?
From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (includinback fill, excavation, rip rap, retaining walls, etc.) in square feet:
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 be impacted (number of trees, for instance):
Oc cii - ( aLonwn
FORM: SSGP 02-2017
Page 2 of 5

11. Signatu e
7/a/u z-z-
Owner/Agent's Signature' [15A NCAC 02H .0502(f)1 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.
b.
c.
d.
e.
All proposed vegetation clearing
Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
Location of any proposed structures such as buildings, retaining walls, docks, etc.
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 Leve
----
Shoreline
FORM: SSGP 02-2017
Page 3 of 5

—J
La ke
(At Full Pond/ Normal Water Level)
Side View
0
LL
4fr'k
Full Pond/ Normal Water Level
Z`horeiine
2 ft.>1150 ft.
additional clearing
• N necessary
E
Plan View
Lake
(At Full Pond/ Normal Water Level)
WI/ illeaira►aiaGaillialliaa`at. Wa
.•.r•••••••••*•i
Existing Dock
30ftz7ft
3ftx 150ft
Below full pond/ NWL
man
Chit 150ft
Above full pond/ NWL
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
I I I
10 ft. bank
height
Side View
Existing bank
•
•
•
AMPLE
FORM: SSGP 02-2017 Page 5 of 5

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION: G t) (2 U'
LOT NO. PLAN NO. PARCEL ID: 0 3q 0 I
STREET ADDRESS: 6 1 C affer P�l 1,
4er 6/A n%c Z73Li3
Please print:
Property Owner:
Property Owner:
der s kfc,
rnOran Lo��
The undersigned, registered property owners of the above noted property, do hereby authorize
, of
(Contractotl/ 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) Ill Q.GJ6Uibib C��— P�/cn(Z, Cjnit 713443
elephone: 3 3( - Z C- Z Z 2 Z_
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
fIALK
''1AuthorizedSignature
yc Date: %/ZFS/ZCZ.
Authorized S'g re
Date: 1 L n-

7/22/22, 9:20 AM
732 BIG DIPPER DR
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NORTH CAROLINA, PERSCN COUNTY
t. 3. Cates, Jr. bail:: duly sworn deposes and
says that he has compiled the above plat from ar.
actual survey by him mace anc that it is co:roct
to the beat of his Icowlodge anc belief. This the
23rc csy of vty, 1966.
Sworn to aid subscribes before me; this the
23 a day. of May,`1966.
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