20150426 Ver 1_Shoreline Stabilization_20150501

20150426
State of North Carolina
- sV 0, Department of Environment and Natural Resources
- ' Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources 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 & Suffer Permitting Unit L y ®
2015
1617 Mail Service Center NB. UW fiA �TRaleigh, NC 27699 -1617 �R a R gs" e ,W r
Applicant Information [15A NC.AC- C2� 10502(a}js
Owner I
Name:
Mailing
Telephone Number: -_V . 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:
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ORiZA T 100 rropim. „cr=) 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.
ll. Project Information [15A NCAC 021 -1 OS42(a) & (o)]
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 property (where work is to be conducted)
County: eee5eo `� o-17 'C!a✓' Nearest Town: 7`-
Subdivision name or site address (include phase /lot number):
Directions to site - please include road names and nu bers, land rks, c..
Q! P
Latitude (in decimal degrees) 1­0 gltude (decimal degrees)
5. Describe the existing land use or conditii of the sit the time of this application
residential undeveloped, etc.)-
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6. Property size (acres) , _5--,-�A�/e--
7. Lake/ river/ ocean adjacent to property..
8. Describe proposed work (include discussion as to how hardening �,Tsn reline h s been
avoided o h it is nec ary). � �O�
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9. Will work be conducted from land? From water? ❑
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below ythenmal pool lake Iev I/ Normal Water Level n square feet or acres:
11 Total amount of disturbance (including all c earing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal
square feet or acres:
12. Please describe the vegetation above the normal pool lake level/
50 feet landward to be impacted
Owner /Agent's Signature
Printed Name
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Agent's signature is valid only if an authorization letter from the owner is provided.
FORM SSGP 10 -2013
57
Date
Page 2 of 3

Full Pond/
Normz'
SI
La ke
(At Full Pond/ Normal Water Level)
T
Please approximately sketch the following information on this plan (provide dimensions for each
1
item, such as 10 ftx 100 ft)* '
1 All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Porid/ 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

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