20150725 Ver 1_Shoreline Stabilization_20150722

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20150725
State of North Carolina
Department of Environment and Natural Resources
i Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: SSGP 10 -2013
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Shoreline Stabilization Application Form
1 Three copies of the application (including attachments) and the application fee should be sent
E to:
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Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699 -1617
Applicant Information j15A NCAC 02H .0502(a)j
Owner Information <
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Name: eA 4 I"lOLN k/*DKSVil tl X
Mailing Address: 36[ o 'rols�-I.t u
l)yly MAl
11@20YIN lop
IJUL 2 2 2015
DENR • WATER RESOURCES
_,401 & BUFFER PERMITTING
c 1036
Telephone Number: 410)(p ID Md Fax Number:
E -mail Address: IM k0Y SVIt cP Vey- zcw - Vl
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:'
htti): / /www.saw.usace.armv.mil/ Portals /59 /docs /regulatory /reedocs /Permits /SAMPLE AGENT A&H
ORIZATION FORM.odf) must be attached if the Agent has signed this application form.
Name: Rlobae G41 (ael
Company Affiliation: !' f'(L _ rS
Mailing Address: 1�S'19 IJr(low,J r7�K
r ; f+lorw0od� �c, 2128
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Telephone Number: 'i0y- q3? —O(vl Fax Number:
E -mail Address: �ollt�i c�l'a� GJinJ5fY -e tM tl
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Person to receive the Certification Approval:%
II. Project Information j15A NCAC 02H .0502(a) & (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.
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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)
County: Mow Y)T't- -e-0 Nearest Town: P? IL fie,-i
Subdivision name or site addriss (include phase /lot number):
­71 jely r� r; b0
f Directions to site - please include road names and numbers, landmarks, etc.:
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! l Latitude (in decimal degrees) ✓ 5, �� " ° (011-ongitude (decimal degrees b I V y
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! 5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): k 4
6. Property size (acres): 4-C ,�e C-S
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):
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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 the normal pool lake level/ Normal Water Level in square feet or acres:
7d �� 47f
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 ini
square feet or acres: r7 D S4, F771-
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): S'Z P_—, /
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ibwner /Agent's gnatu (15A NCAC 02H .0502(f)] 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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SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL �( DESCRIPTION: I'
LOT NO. 102 �T PLAN NO. PARCEL ID: Co5q / o— C�4-53— g%Z4
STREET ADDRESS: Z sm' < W U'rt I !" `oua c teoa /
Please print:
Property Owner: d ej
Korspvt�
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Property Owner: I " cuv KDrsla—cck
The undersigned, registered property owners of the above noted property, do hereby authorize
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of La i d t C &h&jA S
.,,L r-,..,ff.A� , (Contractor / Agent) 0 (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
le W id roV1v l lei, p a lo3S
Telephone: (410) (o L 0 - g d.
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
g at re
Date:

F u I 1'P GMI
Norm a �
Shore lne
p P
Lake
(At Full Pond /Normal Water Level)
k` , F
/3rlo�
�C210
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

Montgomery County, NC
Disclaimer: The information contained on this page is taken from aerial mapping, tax mapping, and public records and is NOT to be construed or
used as a survey or 'legal description'. Only a licensed professional land surveyor can legally determine precise locations. elevations, length and
direction of a line, and areas.
Parcels
Parcel Number: 6576 04 53 8624
Full PIN: 657604538624
Name 1: TRIPLE A ENTERPRISES INC
Address 1: PO BOX 699
City: BISCOE
State: NC
Zip: 27209
House #: 121
Road Name: SUNSET
Road Type: CT
Tax District: LAKE TILLERY FIRE
Township: PEE DEE
Vol. Fire: FIRE DS LAKE TILLERY
Neighborhood: TILLERY TRADITION (WATER)
Legal 1: TILLERY TRADITION
Legal 2: LOT 1024, PH 1, SH 8B
Legal 3: TILLERY TRADIT #1024
Deed Book: 541
Deed Page: 88
Deed Year: 2005
Transfer Date: 20050801
Deed Acres: 0.96
Sale Amount: 290000
Sale Instr: WD
QufiCode: V
Land Value: 259200
Major Imp Value: 958568
Attributes at point: N: 563667, E: 1675818
Misc Imp Value: 24832
Total Value: 1242600
Land Use: N
Appr Code: 01
Appr Desc: RESIDENTIAL
Class Code: 1
Class Desc: RESIDENTIAL
Year Built: 2008
Grade: A +030
Finished Area: 7086
Num Baths: 5.1
Num Bedrooms: 5
Multiple Imp: 001
Fire Districts Townships I Proposed Voting Commissioner's Districts
Name: Tillery Name: PEE DEE District: 1
Zoning Voting District Precincts
Zoning: Residential 1 Name: PEE
City:
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