20150178 Ver 1_Shoreline Stabilization_20150212

$ PAfl/D 20150178
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
1650 Mail Service Center
Raleigh, NC 27699 -1650
n � r
i FEB 1 2 2015
• Applicant Information [15A NCAC 02H .0502(a)] DENR •WATER RESOURC
401 8 BUFFER PERM,nit
1 Owner Information
Name: V, L)dj(ejy -nv-rc Y
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Mailing Address: 73al M i ra P&I- 4c .
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Telephone Number: 919'- Y,09-- -CU,71 Fax Number-
E-mail Address:
2 Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be
downloaded here:
httD / /www saw usace armv mil/ Portals /59 /docs/ regulatory /regdocs /Per_m_ts /SAMP_L_E
AGENT AUTHORIZATION FORM pd f) must be attached if the Agent has signed
this application form.
Name: c-
Company Affiliation:
Mailing Address: ec;AjZ1,(-_ %u�_-slraI Cb 10
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Telephone Number: 3 95(Fax Number:
E -mail Address: ,1 _e_n) �r" Z ?171 Cap O c c on
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Person to receive the Certification Approval: ; -TLAn1,j C"
• Project Information [15A NCAC 02H .0502(a) & (b)j
• 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 plan 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: GC'dc-_.'k1`h2 Nearest Town: BO1f�
Subdivision name or site address (include phase /lot number):
L. a. L-_ VB st a) (--
Directions to site - please include road names and numbers, landmarks, etc
OAJ ccd r _ 204-_ ith r3Q e
cry alas tS a3 .Se.5 Z w;�P i0a5-- as e y-va -0 rs e.
Describe the existing land use or condition of the site at the time of this
application (residential, undeveloped, etc.). m-5iAe_,,A i a J
Property size (acres): 0 3 4 It acres -5
Lake/ river/ ocean adjacent to property:
J
2

• Describe proposed work (include discussion as to how hardening of sh i oreline
has been avoided, or why it is necessary): w ii rk, j . 2 1 t'x,�t,
wc p"e_ i a.l
• Will work be conducted from land? r From water?
• 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:
90 sQ - E-k-
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):
/d - Z _/Y
Owner /Agent's Signature' [15A NCAC 02H 0502(f)l Date
`Agent's signature is valid only if an authorization letter from the owner is provided.

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