20231033 Ver 1_Vicinity Map_20230726

Water Resources
ENVIRONMENTAL QUALITY
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 02-2017
Shoreline Stabilization Application Form
Three copies of the app ication (including attachments) and the application fee should be sent to:
If sending via US Postal Service If sending via delivery service (UPS, FedEx, etc.)
Karen Higgins Karen Higgins
DWR-401 & Buffer Permitting Branch DWR-401 & Buffer Permitting Branch
1617 Mail 5ervi a Center 512 N. Salisbury Street
Raleigh, NC 276 9-1617 Raleigh, NC 27604
A. Applicant Information
1. Owner Informati n
Name:
Mailing Address:
Telephone Num
E-mail Address:
2. Agent/ Contact
A signed and da
signed this appl
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ATION FORM. df)
Name:
Company Affiliat
Mailing Address:
r:
[15A NCAC 02H .0502(a))
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Hwy► N ,L.�? �;S -
3 SII� -otF3 Fax Number:
rson Information
Telephone Numb r:
E-mail Address:
B. Project Information
copy of the Agent Authorization letter must be attached if the Agent has
on form. (A form can be downloaded here:
Fax Number:
1. Attach a vicinity map (i.e. street map) clearly showing the location of the property with
respect to local la dmarks such as towns, rivers, and roads.
2
Provide a detailed site plan showing property boundaries and proposed locations of
vegetation clearing, buildings, retaining walls, docks, impervious surfaces, 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.
FORM: SSGP 02-2017
Page 1 of 3

I Attach a photog aph 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: �(,� "� Nearest Town:
Lake/ river/ ocean adjacent to property:
Property size (acres): Cry
Subdivision name or site address (include phase/lot number):
LEgkM44 cad.
Directions to site - please include road names and numbers, landmar s, etc.:
A
Latitude (!n decimal degrees) . `� If_e Longitude (decimal degrees) -7D�
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):
6. Describe propose I work (include discussion as to how hardening of shoreline has been
avoided, or why il is necessary):
e�
7. Will work be con ducted from land? ® From water? El
8. Total amount of
anent i
Temporary im
pacts below the normal pool lake level / Normal Water Level
(including all�excavation, backfill, rip rap, retaining walls, etc.) in square feet:
in square feet:
9. Total amount of impacts above the normal pool lake
land -ward
I / Normal Water Level and 50 feet
Perma en oac s (includiniz back fill, excavation,ip rap, retaining walls, etc.) in square feet:
Temporary impact (temporary clearing, construction corridor) in square feet:
10. 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):
G ss , +V_�e_ e S
FORM: SSGP 02-2017 Page 2 of 5

11. Slgnatp e
%?wner A 'ent` ignatur * [1 NCAC Q2H .[3502 f
* date
Agent's signat a is valid only if an authorization letter from the owner is provided.
12. Please approxi tely sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
b. Location of tip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of ip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of Iny proposed structures such as buildings, retaining walls, docks, etc.
e. Location of o ny excavation or dredging below the Full Pond/ Normal Water Level elevation
Lake
(At Full Pond/ Normal Water Level)
Full Pond/ !Normal Water
Shoreline
Plan View
1 2-14 F'
r �
FORM: SSGP 02-2017
Page 3 of 5

Lake -
(At Fail Pond/ Normal Water Level)
Side View
Full F
c
0
CL
ore Ine
2 ft. x150k
additional ciearigg w
• If necessary
Plan View
Lake
(At Full9ond/ Normal Water Le el) Existing Dock
ae 30 Rx7R
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P.
AMPLE
FORM: SSGP 02-2017
Page 4 of 5

10 ft. bank
Side Vi
3 ft. below full pond water level
Existing bank
4 ft. above full pond water level
1q,
2 ft. additional clearing
*if necessary
AMPLE
FORM: SSGP 02-2017 Page 5 of 5

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