20150356 Ver 1_More Info Received_20150413

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State of North Carolina
TM Department of Environment and Natural Resources
Division of Water Resources
Resources 15A NCAC 02H 0500— Water Quality Certification, Shoreline Stabilization
Division of Water R
FORM SSGP 10 -2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee shoul#e sent to _
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699 -1617 2 0 1 5 0 3 5 6
1
Applicant Information
Owner Information
Name
Mailing
15A NCAC 02H 0502
Telephone Number /a . &SO. 4>i7b Fax Number
E -mail Address `S4Wc,V Ca rCA143i Aelly; 5Or-1(-a'r"p•COP*A
2 Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here
Ifi / /�v �v� sty a sir z�r��t rt>>I Floruflr r, /�ltacs reE (tar �jregcLpLs /rlermit, /'� NiPLE AGENT AUTHO
RIZATION FORM pdf) must be attached if the Agent has signed this application form
Name ""-Q bG [(e+e; 1PJe p UPDAI &Jip r lft+i- W AJ212tii7C.A ir�fil
Company Affiliation
Mailing Address
Telephone Number
E -mail Address
Person to receive the Certification Approval
Fax Number
II Project Information L15A NCAC 02H 0502(a) &_(0J1
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, etc ),
rip rap, excavation or dredging below Full Pond/ Normal Water Level elevations, and
FORM SSGP 10 -2013 Page 1 of 3

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 CrtR401,J Nea rest Town f3e_ IKorl
Subdivision name or site address (include phase /lot number) �� ��•�� oA�
Directions o site- please include road na�es and numbers, landmarks, etc / X85 S.
°aX cry% 'T CJI�JP.� %3'tNtb T' CAI /.Je 7y Pr L"DN7`1 ymc- OAI
_ho �-_a_wele 61d. "` 0AI S. 1 7-out `Rd.
f'o rJ 4!!N.;27
Latitude (in decimal degrees). 15 Z-- Longitude (decimal degrees) 8>'• RS5-Z
5 Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc ) EX J!PWSDDA o e_xi 5T;t!g MkRiKA
6 Property size (acres) 4 *70
7 Lake/ river/ ocean adjacent to property, 1Vq
8 Describe proposed work (include discussion as to how hardenin of shoreline has been
avoided, or why it is necessary) '51Ai,1,z� s4DV Ft-�.Ver�- etr °s °rl
9 Will work be conducted from land? [✓]' From water? [D'
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
�c,- 6R-0K i9 le S5 + *rJ 7_`A;'J (flihk f(CFD riP rA•P w. Q 43c- i ^r.51*1
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 :3q5 0T1 T-ip rhp W
�i �e i�rsC�rc� whrel�kCJer �--�
12 Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50
feet lapdward to be impacted (number of trees, for instance) VV 00ACA .66ml;1e
/ 3 Ce_ V Kato 5
aA.1� 7' '8" /S
Owner /Agent's Si ature' [15A NCAC�02H 0502(f[ Date
Agent's signature is valid only If an authorization letter from the owner is provided
FORM SSGP 10 -2013 Page 2 of 3

Lake
(At Full:Pohd /Normal Water Level)
7i i4 �U3
i 3
Full Pond/
Normal,IW 'Level" '
7 .. ..
Shoreline
1 , h p h �ri P rip ©or��
CetAArleeJ6p Shp)
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ftx 100ft)*
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
PROPERTY LEGAL DESCRIPTION' (° "A StVA / C�
LOT NO. PLAN NO. PARCEL ID: Z 2�D 13
STREET ADDRESS: Y o % 5 • NEW • o - I It -
De-I MaL'i z)(L Astv-,1-
Please print: J f
Property Owner: A K L i�
Property Owner: 5TC1je-N ( I g 5 k0
LL- -
rTh-
The undersigned, registered property owners of the above noted property, do hereby authorize
(Contractor / Agent) (Name of consulting firm)
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)
42---b 5. 5AA -roAl 4m;I , RJ. 6-r10 4i�,WC -M -J I
Telephone. —7-04, & 50. & 1 7�
We hereby certify the above Information submitted In this application is true and accurate to the
best of our knowledge
Authoriz iogn�at >ure /- Authorized Signature
Date, � �I Z �/ 7 Date. -
i