20150543 Ver 1_Shoreline Stabilization_20150601

State of North Carolina
2 0 1 5 0 5 4 3 Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H.0500 — Water
Division of water Resources
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
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Raleigh, NC 27699 -1617
tDENR �T�Applic ant Information [15A NCAC 0`'H .0 0 (a)r N 0 1 2015 1. Owner Informati n WgTER RESOURCES
Name: GAG'! UFF
Mailing Address: lz4w
Telephone Number: �/`�' %iy �02�� 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:
i tin: I /�nlSi!tl ?,J�'Y.I.53��.�� ��t�r.,�1i1 /Pnrt lsi � /GriCSirL I�IciG; fr /rte Cf�U� /cert'tit5 /�,G.�iIPzF AGENT RUTH
ORIZATION r:on.r 4.;pc4f) must be attached if the Agent has signed this application form.
Name:
Company Affiliation: 'r
Mailing Address:
Telephone Number: Fax Number:
E -mail Address:
Person to receive the Certification Approval:
11. Project Information [15A NCAC 02H .050 '(a) G (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 pro erty (where work is to be conducted)
County: Nearest Town:
Subdivision name or site address (include phase /lot number):
Directions to site - please include road names ao n�pbers, landmarks, etc.:
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Latitude (in decimal degrees) Longitude (decimal degrees)
5. Describe the existing land use or condition of the si at,t e time of this application
(residential, undeveloped, etc.):
6. Property size (acres): , ­5— C :7,
7. Lake/ river/ ocean adjacent to property: lz r C� T� /P��
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necesspry):
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 norr)r al 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 VClater Le I and 50 feet land -ward in
square feet or acres:
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to be impacted (number f trees, for i anc
i
Owner /Agent's Signature
Printed Name
(`1
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10 -2013
Date
Page 2 of 3

La ke
(At Fu H Pond/ Normal Water Level)
Full Pond/
Normal Water Level
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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