20150367 Ver 1_Shoreline Stabilization_20150415

FFjED BAIRD BLACKLEY, ASLA
LANDSCAPE ARCHITECT
:,04 SOUTH DEKALB STREET
SHELBY, NORTH CAROLINA 28150
[phone]
Transmittal
To: i" V� Y��`-'` Attn:
Project: (3�
�� l� ��I des -�►�- Ce--"_ P�;�� -rte.:. ���"�Q,�..,� --�
61-7 Date:jl s�
Copies
Item
Description DD v
3
APR 1 5 2015
CJ"�
�(/!✓
DENR - WATER RESOURCES
494 & BUr ER PERMITTING
u
For: APPROVAL INFORMATION RECORD REQUEST REVIEW COMMENT USE
Remarks:
Copy To: ` By:
Via: US MAIL AIRBORNE__ PICK UP UPS FAX HAND DELIVER OTHER

20150367
Provide three 3 copies of the application and su
O p pp ppohfflng- inforurnati„on (maps, drawings, etc.),
as well as the appropriate application fee (see below), to4he_D visi`ioon of Water Resources,
401 & Buffer Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699 -1617
I Applicant Information
ffOwner Information- Please provide complete and accurate contact information
N❑ Agent Information Per 15A NCAC 0?Fi 0502r, an agent maybe 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
htt wvvw saw usace army milJPorti1�59 /docs /regulaTory /regdocs /Permits /SAiVIPLE
AGENT AUTHORIZATION FORM pdf)
Pr sect 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 (including location information and lat /long coordinates) and
existing features on and near the site
description of project and Impacts/ disturbance proposed
III Si ature
[ Per 15A NCA(- 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 8pplication 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 S143215 3t))
➢ $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)
INSTRUCTIONS FOR APPLICATION SSGP307980 08 -13 & SUPPORTING DOCUMENTATION Page 2 of 3

State of North Carolina
Department of Environment and Natural Resources
{ 3
Division of Water Resources
X�P
} y _
Division of Water Resources
15A NCAC 02H 0500 — Water Quality Certification, Shoreline Stabilization
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
Raleigh, NC 27699 -1617
I. Applicant Information [15A NCAC 0)H _ 1502 a ]
1 Owner Information
Name
Mailing
Telephone Number 10g q j 0 6 Fax Number
E -mail Address Ile -ee—,06 a0�.�1.�D. CoM
2 Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here
YKh�tp1 uvvvvv save us,ac e army mil egdocs P�rfp)) is /SAiVIPLt_ALA N i_ 'A0 I H
ORIZAfION FORNI Ldt) must be attached if the Agent has signed this application form
Name
Company Affiliation
Mailing Address
Telephone Number
E -mail Address
Person to receive the Certification Approval
Fax Number
II. Project Information [151 NCA( 02H 01)u1__tiJ &_('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 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 pr perty (where work is to be conducted)
County __C1 I'VVIU4 Nearest Town
Subdi ision name or site address (include phase /lot number) 'l/
M10
Directions to site - please include road names and numbers, landmarks, etc
VQk V IC/iV1I *" K"
Latitude (in decimal degrees)w i Longitude ( decimal degrees)
5 Describe the existing land use or condition site at the time of this application
(residential, undeveloped, etc) k
6 Property size (acres) kc-oq 4,(,
7 Lake/ river/ ocean adjacent to property
8 Describe proposed work (include discus ion/ as to how hrra^^rdenin& of shoreline has been
avoided, or why it is necessary) I V1SQ1 (-Of r- L1 0– 0,44 �i
9 Will work be conducted from land? From water?
10 Total amount of disturbance (including all excavation, backfili, rip rap, retaining wails, etc )
below the normal pool lake level/ Normal Water Level in square feet or acres
4-7A1' X 1' - V0 Sr
11 Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc ) above the norm..al pool lake level/ Normal Water Level and 50 feet land -ward in
.l
square feet or acres ,I� Z110 �/I a 0 S �_
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)
4An rP n, ,,,, I L - — I C 2 V A
Owner /Agent's Signature
Printed Name
[lsA h2\Cgz�i_u -502 ) )
Agent's signature is valid only if an authorization letter from the owner is provided
_/ llezlell,�_
Date
FORM SSGP 10 -2013 Page 2 of 3

Full Pond/
Normal Water Level
eaA ZMOR
Shoreline
l
La ke
(At Fuii Ponds Normal water Level)
0
Please approximately sketch the following information on this plan (provide d/menslons for each
Item, such as 10 ft x 100 ft)*
1 ✓ All proposed vegetation clearing ������' to
2 Location ofp 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 V, Location of any excavation or edging below the Full Pond/ Normal Water Level elevatiorl-,
6 v Location of construction access corridors
FORM SSGP 10 -2013
Ue � Ca,'�
7TC'
Page 3 of 3

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