20150007 Ver 1_Shoreline Stabilization_20150102

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2 0 9 5 0 0 0 7 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 10 -2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
F#
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699 -1617
Applicant Information [15A NCAC 02H 0502(a)]
Owner Information
Name: 11/ l� /�,� L- C..
Mailing Address: -71 cJ e;) t) 0 c 1.
L-1
1Jc� )e r- 4) h/-c- 2'12-3
JAN 0 2 2015 �
Telephone Number: Fax Number:
E -mail Address: %3 o' (f , ua /:,/ A4, e-
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 armv mil/ Portals /59/ docs /rePulatory /reedocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORMpdf) must be attached if the Agent has signed this application form.
Name: 0 6 i�4' Co., / /-t- 7 1 L
Company Affiliation
Mailing Address:
n
Telephone Number: 1Ci ` -'V3 Z e" 6 1A Fax Number:
E -mail Address: 'r'_
Person to receive the Certification Approval: Z,/,&,.C-7el ,
Project Information [15A NCAC 02H 0502(a) & (b)1
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 locationsbf
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 the property (where work is to be conducted)
County: Nearest Town: �1.�C� k%ct £s d
Subdivision name or site address (include phase /lot number): — rUe --nr L tZ /3c-.el
Directions to site - please include road names and numbers, landmarks, etc
Latitude (in 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.):
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property: Lg. 1,1, -7 Z/
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): K�r' l "'� r ti=} t r
i1) 4,-- 1, C, R- r
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:
Yo -f / y .2 "- �, a <. " ma=y
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): kye, A..J
ZIA Z-- A & Z
Owner /Agent's Signature Printed Name Date
[15A NCAC 02H .0502(f)]
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM SSGP 10 -2013 Page 2 of 3

Full Pond/
Normal Water Level
Shoreline
Lake
(At Full Pond /Normal Water Level)
F t-
I
Ali po "Ud
( It
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

SAMPLE AGENT AUTHORIZATION FORM
PROPEtTY LEGAL D1:
LOT IYO. 2C 7 -Z I • PU N No. PARCEL ID:
STRUT ADDRESS
Please prig n t�
Property owr�: (i� V I A S. lLt"
The undyed, registered p W&W owners of the above noted pmp", do hereby authorize
lu.,t d'"BRA of,
(Cdnb actor / Agent) I Olm a of conadfing firm)
to ad c6 niy bdW and take all adWm neoessary for the prang, Isstranoe and amgtance of
this permit or cemcatlar and any and a8 standard and specW cmuMim attached.
Property owner's Address Of different than property above):
Tdeo't m
Vow hereby certify the above information submitted in oft application is true and ammate do the
best of our Imowledom
`41

OBJEt- D
Tax Record
Owner Name
5278899
137761
CIVITAS LLC
Owner Name 2
_ Mailing Address
_ Mailing Address 2
712 WOODCLIFF CT
CSC
State
Zip
WAXHAW
NC
28173
PIN
Deed Acres
Lots
657302665756
035
0
Physical Address
District Code
District Desc
WOOD LAND DR
112
CENTER FD
Township Code
Township Desc
Descriptionl
122
EAST CENTER TWP
VACANT
Year Built
Finished Area
Land Value
0
124162
Other Value
Total Value
Deed Book
0
124162
1488
Deed Page
Plat Book
Plat Page
707
5
13
Building Value
Landuse Record
0
No
This map is prepared for the inventory of Real Property found within this jurisdiction, and is compiled from recorded deeds, plats and other public records and data
Users of the map are hereby notified that
the aforementioned public primary information sources should be consulted for verification of the information contained on
this map The Stanly County Geographic Information Systems Division of the Office of Information Technology assumes no legal responsibility for the information
contained on this map Also, when the deeds and or plats are viewed for a parcel, the Stanly County Register of Deeds Office makes no guarantees regarding the
collection, accuracy, authenticity, or use
of these records The web site is for informational use and
convenience only The Register of Deeds shall in no way be held
responsible for errors or omissions in these
records nor for any actions resulting from their use
The official records are kept in the Stanly County Register of Deeds
Office To view deeds on this site you must install the AlternaTIFF viewer To install, please visit http
Hwww alternatiff com /install -ie/