20150071 Ver 1_Shoreline Stabilization_20150120

State,ofrNorth Carolina
2 0 1 5 0 0 7 1 Department of Environs ntfand NaturResources
Division of Water Resources
15A NCAC 02H 0500 — Water Quality Certification, Shoreline Stabilization
Division D—,WR
Water Resources FORM SSGP 10 -2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center JA AV
Raleigh, NC 27699 -1617 0 23 15
S1 RMWq�,rI D Q1 / , /Ty
Applicant Information [15A NCAC 02H 0502(a)] h'P= &Q/7TING
1 Owner Information
Name
Mailing
MEMO
Telephone Number
E -mail Address
Fax Number
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 /does /reRulatory /re2docs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM pd f) must be attached if the Agent has signed this application form
Name MAUL l^i lr- Ast-l�2L
Company Affiliation -Wck-4 u Mi 5 V 7' LC,
Mailing Address 19IL°n -I-
s
Telephone Number 104. 5Q8 11Li 0 Fax Number '104. Ga98.3 00
E -mail Address WX_C. C oOAti
Person to receive the Certification Approval
II. Project Information [15A NCAC 02H 0502(a) & (b)]
1 Attach a vicinity map (i a 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 the property (where work is to be conducted)
County Me.Gl_l Nearest Town GO r ned" u.$
Subdivision name or site ad ress (include phase /lot number) YAC - ThA&,J S�CP
R 3C6 VACA- MAA-,l �DQ . C L-01 1
Directions to site - please include road names and numbers, landmarks, etc
-X-1-1 �o Ex % �- 2
Ors
Latitude (m decimal degrees) 96_4'V7 I 'i Longitude (decimal degrees) —k0. W45—
5 Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc ) 1�2S%Aer1 -�l & I
6 Property size (acres) & . SV
7 Lake/ river/ ocean adjacent to property
8 Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary) DreckAe Tv-, 10 ` ck.L2-h
9 Will work be conducted from land? ❑ From water? (7
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
,5-/S- LLd_-,1C_ Llard'g
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
E-02
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)
Owner /Agent's Signature
Printed Name
FAr
[15A NCAC 02H 0502(f)l
Agent's signature is valid only if an authorization letter from the owner is provided
i
Date
FORM SSGP 10 -2013 Page 2 of 3

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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

EXAMPLE
Lake
(At Full Pond/ Normal Water level)
, Dock
30ft x7ft
Excavated Area
25ftx150ft
Rip Rap
Full Pond/ 3 ft x 150 ft
Normal Water Level • • ; Below full pond/ NWL
■ ! ! ! ! i r1 i i ��1
Shoreline
•• • • • Rip Rap
Cleared Area 3 ft x 150 ft
• • • Above full pond/ NWL
8 ft x150ft '
Lot A
Additional clearing
Existing �.. 5 ft
I �5ft
10 ft /
Ij/ Proposed
INSTRUCTIONS FOR APPLICATION SSGP307980 08 -13 & SUPPORTING DOCUMENTATION Page 3 of 3