HomeMy WebLinkAbout20150601 Ver 1_Shoreline Stabilization_201506172 0 1 5 0 State of North Carolina
Department of Environment and Natural Resources
t° 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 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699 -1617
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JUN
F 1 y 2015 D'
1. Applicant Information f 15 NCAC 022H .0502(a)j 4 BUFq R'pE� R
1. Owner Informa�tiion�� �s ��
Name: �/� s� /�. ham'! l/ /0
Mailing Address:
Telephone Number: 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:
ocs/reRu1ator,r /reRdoe,/ hermits /SAMPLE AGENT AU T H
ORIZAT!ON F0ErV1. -df) 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:
I1. Project Information (15A NCAC 02H .050-21a) Ul -
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
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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)
:
y
Count SSG, Nearest Town:
- -
Subdivision nam or site address (include phase /lot number):
v
Directions to site - please include road names and numbers, landmarks, etc.:
4j
Latitude (in decimal degrees) LongiVde (decimal degrees)
5. Describe the existing land use or condition of the:si ' at. -the time of this application
(residential, undeveloped, etc.): �"�Si�71
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property: _Il�i-r/
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): _� /QC_
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 Water Level in square feet or acres:
Ab
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:
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and "
50 feet landward to be i pacted (number of trees, for in ance):
v
Own gent's Signature* Printed Name 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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NOT FOR; RECORDIN(
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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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