20150012 Ver 1_Application_20150102

201 50006
State of North Carolina
AM DWR P Department of Environment and Natural Resources
Division 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 application fee should be sent
Division of Water Resources ,2 Y J
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699 -1617
Applicant Information [15A NCAC 02H 0502(a)]
1. Owner
2
Name:
Mailing Address:
I�-1 b /` fy.L, 220t,'
> --
Telephone Number: '26cl- L= .�I2- c� Fax Number:
E -mail Address: 1= '�;p—,'tp
Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http //4irww saw usace army mil/ Portals /59 /docs /regulatory /regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM df) must be attached if the Agent has signed this application form.
Name• b (:r k_ \ I A--I' L t�-
Company Affiliation:
Mailing Address:
A c 5 'i N C= C_ c� r,A 4-'P� 0-tv P_
N] IL, L_$ 1 Z
Telephone Number: Z�`/ `/3 b �' �' Fax Number:
E -mail Address: 1 h, t.Lt L1 W ry g e6-A`t-N, , Al- 6
Person to receive the Certification Approval: 9a b i Y1- F rr R
II. 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

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 a property (where work is to be conducted) p
County: J ►�° 11 Nearest Town:
Subdivision name or site address (include phase /lot number):
sctions to site - please include road names and numbers, landmarks, etc
J x---
Latitude (►n 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.): , rZ i CQ LA' 4f J
6. Property size (acres): Z2. D — r2
7. Lake/ river / ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening shgreli a has been
avoided, or why it is necessary)- -111 0A e /I tv F `- �' '/P - 77 0 A.)
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:
f.2 l) F�- V -3 F_ - 3 & o s T="1-
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:
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 &�V e72c % S r l/
�c G
Owner /Agent's Signature
i V, /-� -
Printed Name
[15A NCAC 02H 0502(f)l
Agent's signature is valid only if an authorization letter from the owner is provided
�-/ y -/
Date
FORM SSGP 10 -2013 Page 2 of 3

Nor
Full Pond/
Shoreline
La ke
(At Full Pond/ Normal Water Level)
3 F -k
p p,b e-- -FL,
j 'b,:--57 (0 LJ tUl�
3 -
t�C+ � �1
t-�
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

PROPERTY LEGAL. DESCRIPTION:
L.AT NO. It 2' PLAN NO. PARCEL ID:
LA 'IENM
Please prm f
Property Owner: Lcwec -
The undersVW, registered property owners of the above noted property, do hereby authorme
or, .((Ls Lajn�
( /) (Na constAft
m
to act on my behaff and twice afi actions necessary for the proofing. isstsnoe and aooeptance of
this permit or car and any and a8 standard and spedal caimans attached.
Property Owner's Address (if Mae t than property above):
Teleptmm
Vbe hereby certify the above information wbmitbed in this application 15 true and aacurabe to the
best of or imowledg&
Date: / ., lY7 /V
Date.,
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