20150489 Ver 1_Shoreline Stabilization_20150514

2 0 1 5 0 4 8 9 State of North Carolina
DWR r Depart ent of,Enviro rrient and Natural Resources
�'� aision of Water Resources
Division of Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
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
1. Applicant Information [15A NCAC 02H .0502(a))
1. Owner Information
Name: M u-!/ -r»v n al' _�i
Mailing Address: Lv k -('t1: Ja i 9/c .
Telephone Number: QIq Fax Number:
E -mail Address: j- h rnst-an� ��:�e- y�C�drZi('��,,�
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
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: _S�� v .e 0.7 to n e
Company Affiliation: Ph I 's L?u 14 L �Cc, L, 5 t22p c j ja&
Mailing Address:
Telephone Number: C�TaS`A6!5 ` Fax Number:
E -mail Address: Y"e-., CIOC7r,� .'/.
Person to receive the Certification Approval: Siev o
11. Project Information [15A NCAC 02H .0502(a) & (b)J
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 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 conducted)
County: l=ra71 K /__iAt Nearest Town: A o, )N dl
Subdivision name or site address (include phase /lot number): L 4
10 q Sac► a r-o Dr, to" is baNrj }'j� z75 4 Y ���'1'-� Ag
Directions to lease include road names and numbers, landmarks, etc.:
Chav4hA_, 'tUrh
- ,y eR ; � I o °1
,
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Ca, ,np i n g Lc,-r, 0- e Li -YhA %Arr, , #AtDJ
6. Property size (acres): . i arc 6k!!5
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Ai Lie Li, d -1-o Plv y.a,. 7 E rc.s , vwr `6 3 ­e 3,r,1-
9. Will work be conducted from land? 2� From water? El
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:
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: 1
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): 4{�
L? ruts S N L u �7 f►^.o ✓S (W r t
Owner /Agent's Signature* [15A NCAC 02H .0502(f)l
as cis—
Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10 -2013
Page 2 of 3

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Lake
(At Full Pond / Normal Water Level)
Full Pond/
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Shoreline
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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 construction access corridors
FORM. SSGP 10 -2013 Page 3 of 3

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MAY
U.S. ARMY CORPS OF ENGINEERS I i -- I Form Approved -
APPLICATION FOR DEPARTMENT OF THE ARMY PERMITi.'ia •V11Fii, {;� .. loafs No. 0710 -0003
. _
X01 8 Cr1,== 'F Expires: 3"EPTEMBER -2015
33 CFR 325 The proponent agency is CECW -CO -R __s., -- • ,_ ~i
Public reporting for this collection of information Is estimated to average 11 hours per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of the collection of Information, including suggestions for reducing this burden, to Department of Defense,
Washington Headquarters, Executive Services and Communications Directorate, Information Management Division and to the Office of Management and
Budget, Paperwork Reduction Project (0710 -0003) Respondents should be aware that notwithstanding any other provision of law, no person shall be
subject to any penalty for fading to comply with a collection of information if it does not display a currently valid OMB control number Please DO NOT
RETURN your form to either of those addresses Completed applications must be submitted to the District Engineer having jurisdiction over the location of
the proposed activity.
PRIVACY ACT STATEMENT
Authorities. Rivers and Harbors Act, Section 10, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; Marine Protection, Research, and Sanctuaries
Act, Section 103, 33 USC 1413, Regulatory Programs of the Corps of Engineers; Final Rule 33 CFR 320 -332. Principal Purpose: Information provided on
this form will be used in evaluating the application for a permit Routine Uses. This information may be shared with the Department of Justice and other
federal, state, and local government agencies, and the public and may be made available as part of a public notice as required by Federal law. Submission
of requested information is voluntary, however, If information is not provided the permit application cannot be evaluated nor can a permit be issued. One set
of original drawings or good reproducible copies which show the location and character of the proposed activity must be attached to this application (see
sample drawings and /or instructions) and be submitted to the District Engineer having jurisdiction over the location of the proposed activity An application
that is not completed in full will be returned
(ITEMS 1 THRU 4 TO BE FILLED BY THE CORPS)
1 APPLICATION NO
2 FIELD OFFICE CODE
3 DATE RECEIVED
4 DATE APPLICATION COMPLETE
(ITEMS BELOW TO BE FILLED BYAPPLICAN7)
5 APPLICANTS NAME /(
/Middle
8 AUTHORIZED AGENT'S NAME AND TITLE (agent is not required)
First - f 4 � C - Last - h MT.5 r@rt�
First - S' -� Y °+� Middle - W(Xy'hi— La/st.- PCI&I'Ae/
Company J 11
Company - p�'1 l C �QZ t t% C[9%ts! I-U,ct t O�
E-mail Address �y- S f �f p
E -mail Address ;
6. APPLICANTS ADDRESS '
9. AGENTS ADDRESS.
Address- 1016(1 ' �`
Address - P o g n A i G(
City- oq1i GAre State- Zip- Coun -
City- t?Y7\ State- -},'C Zip -, 75e Coun
7 APPLICANTS PH E NOs WAREA CODE
10 AGENTS PHONE NOs. w /AREA CODE
a Residence b Business c Fax
a. Residence b. Business c Fax
STATEMENT OF AUTHORIZATION
11 1 hereby authorize.. 9—e / L n to act in my behalf as my agent in the p ocessing of this application and to furnish, upon request,
supplemental information in support of this permit gppication ' y
//SIGNATURE OF AP LICA DATE
a
NAME, LOCATION, AND DESCRIPTION OF PROJECT OR ACTIVITY
12 PROJECT NAME OR TITLE (see instructions)
t `
J r One
13. NAME OF WATERBODY, IF KNOWN (if applicable)
14. PROJECT STREET ADDRESS (if applicable)
L46 &YdLe
Address ioq S (xgct -ygtpt , p r
City - &� State - }S �", Zip-
Loco . ,
15 LOCATION OF AROJEET
Latitude -N Longitude: =W
v `
16 OTHER LOCATION DESCRIPTIONS, IF KNOWN (see instructions)
State Tax Parcel ID Municipality
Section - Township - Range -
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