20150131 Ver 1_Shoreline Stabilization_20150202

Shoreline Stabilization Application Form 2 0 1 5 0 1 3 1
Three copies of the application (including attr,c, •rents) and the application fee
should be sent to:
Division of Water—Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699 -1617
Y
Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: JQain %ont-k Lj-_)GA
Mailing Address: 3 od b�. ron_ J
C,kc" 10 4k_) A] - ')_S-2_77S_
Telephone Number: 70'4 "5_5�1—004 ( Fax Number:
E -mail Address: dpo /060 iIJ040 4 /� 1'iC hadage �yl�
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 army mil/ Portals /59 /docs /regulatory /regdocs /Permits /SAMPL
E AGENT AUTHORIZATION FORM pdt) must be attached if the Agent has signed
this application form.
Name: (i,l AJAIS is e r�� L- 'L 'l , .Loc.
Company Affiliation: 'kajid!4 Oa-WSon nt mer
Mailing Address: 5�So5 e�}a "�,��. �QrMc . S.C.
7-J-7 10
1

Telephone Number: -6-o3 - 4s31- 16-31 U Fax Number: $03 - 4s3
5(.55
E -mail Address: ( -J.Lv. -' 35 C.
Person to receive the Certification Approval: To.4. ,, C6-ws -Qfn
® Project Information [15A NCAC 02H .0502(x) & (b)]
• 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.
• Provide a detailed site place showing property boundaries and proposed
locations of vegetation clearing, structures (buildings, retaining walls,
docks, impervious surfaces, 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.
• Attach a photograph of the shoreline/ buffer proposed to be stabilized.
(Include a scale of some sort- a yard stick, shovel handle, etc.)
© Location of the property (where work is to be conducted)
County: G.,S- On Nearest Town: 7--elwuoa,+
Subdivision name or site address (include phase /lot number):
LQo - -4 U LA kA- fro;�� scA6�k�V -111 Or,
�U2Ir►Wm'\} I A -C• ?-ac i
Directions to site - please include road names and numbers, landmarks, etc.:
5D,,pt, nn NC �7R _ 4-u,A le-r� an Loge -- hr'mgh'v »g _
/,a roc/es fur✓! (e-LL on-l?, l�en,r(sw /a �►�.
OAJ on +1L' le-4
Latitude (m decimal degrees) J5 n 10' A oZ I rl N Longitude (decimal degrees)
® Describe the existing land use or condition of the site at the time of this
application (residential, undeveloped, etc.): IZeAIdew.11a
® Property size (acres):
0 Lake/ river/ ocean adjacent to property: IAI V I i 2

® Describe proposed work (include discussion as to how hardening of shoreline
has been avoided, or why it is necessary): 45 ii „L& t^c”, f rosQt e, ,`S -5-f'W
/hr1'.u6CiAC tv,7IA _'(i //...n (.�-ti e.�f m,ntdL— '�'r�P..S. OHP6—
OIAI
® Will work be conducted from land?/,,,,k From_oatesm
a 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: ,5-0o s w nC,Pax wu%�el 1ev��
11. Tota(amount of di turbance ( including all clearing, back fill, excavation, rip
rap, retaining walls, etc.) above the normal pool lake level/ Normal Water
Level and
�t CCcS 50feet land -ward in square feet or acres
: l �t I
a _ o ;,5 far�a­&e-
12. Please � ra,ES l .J� k
d scribe the vegetation above the normal pool lake (evel/ Normal f unni"1y ° ✓� %`
Water Level and 50 feet landward to be impacted (number of trees, for
instance): )—V-2 st & OL�-e_ , 5"d'o %, n G s , T - -71-r-c- P;G 4-1, on C-�i e- 0�A'4 -
!^ J - i e-d 4re-
am cC ✓1 e� -� U 2� �P»/o ✓�. �o i � O - f- �S V'i 1 i a ,
Gtr �re1c5 /��c f ct� hof/��ea�2/ y��✓��O[��1�
Al / �r�f��( ✓ ✓arecti - J— IK1a /G/It (,t/Y`� iirt;slltl�
Owner /Agent's Signature* [15A NCAC 02H .0502(f)]
Date
'Agent's signature is valid only if an authorization letter from the owner is provided.

.'
-�
Ham2 insert
Dem,7n :mlmatl..ns Slid- Show Rehry
'l +Lw lnsertlth2
--__j J�2�Lt
-
-
_ •-. ,L
Pair,
77e•� �s . 'a S t 1
_ _ _
_ <- = �' 14` i .
;� �i �� { f
"J Delete
�3t3.J'3ph
jR
Lake
u , (At Full Pond / Normal Water Level)
u _
ti
13Y �I
i
i'
44
Y 1a-
a-- r,
V
I
SUtle d ofd Ottlte Theme
Full Pond/
Normal Water Level Cr .�aa
r --- t co
Shoreline;<r`i�"
to +fe
ewA°�`,G�-
V- , k
Please approximately sketch the following information on this plan (provide
dimensions for each item, such as 10 ft x 100 ft) *:
• All proposed vegetation clearing
• Location of rip rap or fill to be placed above the Full Pond/ formal 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
4

• Location of construction access corridors

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 10 PLAN NO. PARCEL ID:
STREET ADDRESS: 16A1 P
nihS11 1a i7r
Please print:
Property Owner:
Property Owner:
%I 1
The undersigned, registered property owners of the above noted property, do hereby authorize
A(AJ1411 NO cT (0}� b
(Contracto / Agent) (Name of consulting firm) j L
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):
-� 2 —Eld gel ron U. Cl r rlollP N(- Qf)-B
Telephone: log - O n4
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature Authorized Signature
Date: , / /fie b / Date:

UE)
U
m
Y21 Peninsula Dr
r.,

THIS IS TO CERTIFY THAT ON THE 4 DAY OF November 20 14 AN ACTUAL
SURVEY WAS DONE UNDER MY SUPERVISION OF THE PROPERTY SHOWN HEREON. THIS MAP IS O 1T INTENDED
TO MEET GS 47 -30 RECORDING REQUIREMENTS.
SIGNED _ Ce t� I IiM4
Bishop Land Surveyi "g, Inc.
z 10719 Trolley Run Dr.
Cornelius, N.C. 28031
Phone: [phone]
Business License #. C -2674
L :GEND
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t:.tIOPPROIICT :AtIt JAtION
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FICAI
LINE TABLE
LINE
LENGTH
BEARING
1.1
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L2
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L3
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I N32 17'32-W
L4
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f 54'S9'W
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19.40
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LOT 5
LANE mw xvut opurN, cm,
Its 4354 PG 517
G 35
LAKE WYLIE
PROPERTY LINE IS DUKE ENERGY CORPORATE BOUNDARY
AND APPROXIMATE FULL POND CONTOUR OF.570.0'
100 YEAR FLOOD CONTOUR I F.P.E. = 571.0' /
(F.E.M.A. PANEL k: 3710359200 J DATED, 928.2007) f
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