20150154 Ver 1_Shoreline Stabilization_20150205

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State of North Carolina
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Pt Department of Environment and Natural Resources?
,W Division of Water Resources
- y 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources
FORM SSGP 10 -2013
Shoreline Stabilization Application Form
Four 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
Raleigh, NC 27699 -1617 p
I. Applicant Information [15A NCAC 02H 0502(a)]
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1 Owner Information
DENR •WATER RESOURCE
Name 0 r\ 401 &BUFFERPERMITTIN'
Mailing Address 3 a
Z �au� n U C
Telephone Number H -M -C Y/ Fax Number 2101 a - &Ake
E-mail Address rme�Sa„�'I-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 army mil/ Portals /59 /docs /regulatory /regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM pd f) must be attached if the Agent has signed this application form
Name
Company Affiliation
Mailing Address
Telephone Number Fax Number
E -mail Address
Person to receive the Certification Approval
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 4

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- j- ran k ) , r1 Nearest Town- _ u n
Subdivision name or site address (include phase /lot number)- 6,�Q (�
Directions to site - please include road / e n
names and numbers, landmarks, etc
5. Describe the existing land use or condition of the site at the time of this application
residential ndeveloped, etc.) euc 00ec res'yYn -t"'
6. Property size (acres) -33 dere //
7 Lake river/ ocean adjacent to property: _ G�Cxlecl go 'n "/V
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary).
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 Lev I in square feet or acres
dred5e 4- AalkkeQd /6'X19
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. Sea _3 Sn Linrrt' i4 c-e e-
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)- (2ra In o
-tr e es /` /x s J6__ cat s - �Ur d e d g r en
". L_' '�'7 &_'_ - I
Owner /Age 's Signature* [15A NCAC 02H 0502(f)] Date
'Agent's signature is valid only if on authorization letter from the owner is provided
FORM SSGP 10 -2013 Page 2 of 3
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Division of water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification
Instructions for Application FORM SSGP 10 -2013
(Shoreline Stabilization 401 WQC to accompany USACE GP30, GP79, or GP80)
Instructions for Shoreline Stabilization Application
When to use this form —This application form should be used to apply for a 401 Water Quality
Certification to impact:
When this form should not be used —This application form cannot be used for wetland or
stream impacts. This information does not apply to landowners within the twenty coastal
counties that are affected by Division of Coastal Management (CAMA) rules.
For more information — if you have been advised that you require a 401 Water Quality
Certification, and would like more information about:
➢ The application process. http / /portal.ncdenr.org/ web /wq /swp /ws /401 /certsandpermits
➢ How to download an application form.
http //portal ncdenr orp/ web /wq /swp /ws /401 /certsandpermits /apply /forms
➢ Application fees: -
http. / /portal.ncdenr org/web/wq/swp/ws/401/certsandpermits/apply/fees
If you are unable to download this information or application, please call (919) 807 -6300 to
request an application with instructions.
Please note — Not all impacts require written authorization from DWR. This may include the
construction of docks or boathouses if there is no dredging or filling involved (other than the
pilings). For more information, please visit the following website:
http: / /Portal.ncdenr org/ web /wq /swp /ws /401 /certsandpermits /fags #always have to apply
How to _apply — When submitting an application to DWR, please use the following instructions
as a checklist in order to ensure all required items are submitted. Adherence to these
instructions will help facilitate a quicker review time and reduce the amount of requested
additional information.
INSTRUCTIONS FOR APPLICATION SSGP307980 08 -13 & SUPPORTING DOCUMENTATION Page 1 of 3
U.S. Army Corps of
Description
Engineers (USACE) Permit
Federal Energy Regulatory Commission (FERC) regulated lake
GP30
shore or bottom
Tennessee Valley Authority (TVA) regulated lake shore or bottom
GP30
Local government regulated lake shore or bottom
GP30
USACE Reservoir owned /regulated lake shore or bottom
GP79
Private lake shore or bottom
GP80
When this form should not be used —This application form cannot be used for wetland or
stream impacts. This information does not apply to landowners within the twenty coastal
counties that are affected by Division of Coastal Management (CAMA) rules.
For more information — if you have been advised that you require a 401 Water Quality
Certification, and would like more information about:
➢ The application process. http / /portal.ncdenr.org/ web /wq /swp /ws /401 /certsandpermits
➢ How to download an application form.
http //portal ncdenr orp/ web /wq /swp /ws /401 /certsandpermits /apply /forms
➢ Application fees: -
http. / /portal.ncdenr org/web/wq/swp/ws/401/certsandpermits/apply/fees
If you are unable to download this information or application, please call (919) 807 -6300 to
request an application with instructions.
Please note — Not all impacts require written authorization from DWR. This may include the
construction of docks or boathouses if there is no dredging or filling involved (other than the
pilings). For more information, please visit the following website:
http: / /Portal.ncdenr org/ web /wq /swp /ws /401 /certsandpermits /fags #always have to apply
How to _apply — When submitting an application to DWR, please use the following instructions
as a checklist in order to ensure all required items are submitted. Adherence to these
instructions will help facilitate a quicker review time and reduce the amount of requested
additional information.
INSTRUCTIONS FOR APPLICATION SSGP307980 08 -13 & SUPPORTING DOCUMENTATION Page 1 of 3

Provide four (4) copies of the application and supporting information (maps, drawings, etc.),
as well as the appropriate application fee (see below), to the Division of Water Resources,
401 & Buffer Permitting Unit, 1650 Mail Service Center, Raleigh, NC 27699 -1650.
Applicant Information
❑ Owner Information: Please provide complete and accurate contact information
❑ Agent Information Per 15A NCAC 02H .0502 , an agent may be given signatory
authority for the owner /applicant if a signed and dated copy of an Agent Authorization
letter is included with the application. (A sample form may be found at
http- / /www. saw. usace.army.mi I /Porta Is /59 /docs /regulatory /regdocs /Perm Its /SAMPLE
AGENT AUTHORIZATION FORM.pdf)
II. Project Information
❑ Vicinity/ Site Map: Some type of site map so that someone unfamiliar with the area can
locate your project. A county map or USGS topographic map indicating the project
location is usually sufficient.
❑ Site Plan: A site plan showing the location of the shoreline, location of the impacts to
the shoreline and /or lake bottom and the location and any vegetated areas that will be
Impacted. In most cases the site plans do not have to be professionally prepared.
However, if you intend to conduct hydraulic dredging, professionally prepared drawings
will likely be required for the spoil structures. See example below
❑ Photograph of shoreline to be impacted/ disturbed
❑ Description of property and existing features on and near the site
❑ Description of project and Impacts/ disturbance proposed
Ill. Signature
❑ Per 15A NCAC 02H .0502 , the application shall be considered a "valid application" only
if it bears the signature of a responsible officer of the company, municipal official,
partner or owner. This signature certifies that the applicant has title to the property, has
been authorized by the owner to apply for certification or is a public entity and has the
power of eminent domain.
IV. Application Fee
❑ The application must be accompanied by the appropriate application fee (checks made
out to the NC Division of Water Resources). The application fee is as follows (pursuant
to G.S. 143 -215 3D)
➢ $240.00 for impacts to lake (below normal water level) of less than 1 acre
➢ $570.00 for impacts to lake (below normal water level) of greater or equal to 1 acre
INSTRUCTIONS FOR APPLICATION SSGP307980 08 -13 & SUPPORTING DOCUMENTATION Page 2 of 3

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Scale: 1 "= 50' Date: July 2, 2014
50 0 50 100 150
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WILLIAM T. DEMENT, JR., Professional Land Surveyor, P.A.
L -1456, C -0649
919- 496 -6159
102 West Nash Street Louisburg, N C 27549 (File No 3637)

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(Property Owner- Tom Long, et ux)
1701 Sagamore Drive, Cypress Creek Township, Franklin County, NC
Scale: 1 "= 50'
50 0 50 100 150
GRAPHIC SCALE - FEET
Surveyed & Mapped By
WILLIAM T. DEMENT, JR., Professional Land Surveyor. P.A
L -1456, C -0649
919- 496 -6159
102 West Nash Street Louisburg, N C
Date: July 2, 2014
27549 (File No 3637)

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