20150380 Ver 1_Shoreline Stabilization_20150420

State of North Carolina
DWR 2 O Department of Environment and Natural Resources
1 5 0 3 8 0 0Divisioonn of Water Resources
15A NCAC 02H 0500 -Water Quality Certifi¢ation,�'Sh ► i��� �bihzation
Division of Water Resources 1r�
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
1650 Mail Service Center
Raleigh, NC 27699 -1650
Applicant Information [15A NCAC 02H 0502(a)]
1 Owner I
Name
Mailing Address
Telephone Number a- '�$-�� y� 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
http / /www saw usace army mil/ Portals /59 /docs /regulatory /regdocs /Permits /SAMPLE AGENT AUTH
' - l
ORIZATION O� RM Pd f must be attached if the Agent has signed this application form
N a m e. .TrN
Company Affihatio'n'-��- 'CY1
Mailing Address Cik c
Telephone Number �`b�1 11x3 Fax Number
E -mail Address
Person to receive the Certification Approval.
H. Project Information [15A NCAC 02H 0502(a) & (b)]
1 Attach a vicinity map (i a 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
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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 condu ted) `
County �cct�.+C3 n Nearest Town
Subdivision name or site address (include phase /lo mb
Directions to site - please include road names and numbers, landmarks, etc
5 Describe the existing land se or condition of the site at the time of this application
(residential, undeveloped, etc) v
6 Property size (acres) e_
7 Lake/ river/ ocean adjacent to property
8 Describe proposed work (includ discussion as to how hardening of sho (eline 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 Watvr Level in square feet or acres
tea, -It 3 _ \.\ 0--k-0 zz�
11 Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc ) above the normal pool lake level/ Normal Water Leve and 50 feet land -ward in
square feet or acres- X
12 Please describe the vegetation above the normal pool lake level/ N al Water Level and
50 feet landward to be impacted (number of trees, for instance)
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
FORM SSGP 10 -2013 Page 2 of 3

FI
Norm<
S
La ke
(At Full Pond/ Normal Water Level)
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft) *
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 constructio ess corridors
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FOR SGP 1 -2013
Page 3 of 3
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Print - Maps
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8426 Catawba Cove Dr, Belmont, NC 28012
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Print - Maps
LV bing Maps
A 5850 Charlotte Hwy, Clover, SC 29710
B 8426 Catawba Cove Dr, Belmont, NC 28012
Route: 6.1 mi, 11 min
A 5850 Charlotte Hwy, Clover, SC 29710
1. Depart SC-49 / SC -274 toward Catamount Dr
Page 1 of 1
My Notes
On the go? Use m.bin9.com r f—
directions. businesses an, r-
A —B: 6.1 mi
11 min
1.8 mi
1 2. Keep straight onto SC -274 0.9 mi
F 3. Bear right onto SC -177 / Pole Branch Rd 1.9 mi
4. Turn left onto Catawba Cove Dr 1.5 mi
Entering North Carolina
B 5. Arrive at 8426 Catawba Cove Dr, Belmont, NC 28012
The last intersection is Garden View Ct
If you reach Catawba Winds Dr, you've gone too far
These directions are subject to the Microsoft® Service Agreement and for informational purposes only No guarantee is made regarding their completeness or accuracy
construction projects, traffic, or other events may cause actual conditions to differ from these results. Map and traffic data 02015 NAVTEO "'.
http: / /www. bing. com /mapslprint.aspx ?mkt= en- us &z= 13 &s =r &cp= 35.127009,- 81.077521 &... 4/8/2015

Agent Authorization Form
PROPERTY LEGAL DESCRIPTION
LOT NO PLAN NO
STREET ADDRESSy
Please print
Property Owner
Property Owner
z�
PARCELD
The undersigned, registered property owners of the above noted property, do hereby authorize
- err. X- CXZ)me. ,of � 6�e— t)
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permdor certification and any and all standard and special conditions attached
Property Owner's Address (ifdifferentthan property above)
Telephone
We hereby certify the above information submitted in this application is true and accurate to the
bestof our knowledge
Signature
v _
(— I J Date ar