20150797 Ver 1_Shoreline Stabilization_20150806

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State of North Carolina
D WR Department of Environment and Natural Resources
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 7
I. Applicant Information (15A NCAC 02H .0502(x)]
1. Owner Information
Name: _ A Y �.�,� f, � <.._ /'e-e" ;.
Mailing Address: 10 _J°` 44 A ,.
Telephone Number: ��:;r- 47d'- 2,�r<YFax 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:
http: / /www. saw. usace. armv. mii / Portals /59 /docs /regulatory /regdocs /Permits /SAMPLE AGENT RUTH
ORIZATiON FORM.pdf) must be attached if the Agent has signed this application form.
Name: �' �,� ,✓ °x�2 �i �~
Company Affiliation:_
Mailing Address:
0 Al IV
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Telephone Number %�'Y_2, Fax Number:
E -mail Address: x}}41.1 _ 417, 4q ` j ,'n
Person to receive the Certification Approval: ,5- f r /00 x, "Y.
Project Information f 15A NCAC 02H .0502(a) & Ml
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 property (where work is to be conducted)
County: Fr 4 z '-4'1 Nearest Town: %'°� � ,o, "d
Subdivision name or site address (include phase /lot number): ---4ALe�;e
Directions to site - please include road names and n umbers, landmarks, etc.:
r' .� � IJ J c--), :<s } i
,!
Latitude (in decimal degrees) •`% /)i Longitude (decimal degrees) i1 %
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):
6. Property size (acres): G
7. Lake/ river/ ocean adjacent to property: _J A '0�q'e g a7 s
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 6
9. Will work be conducted from land? i�' 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:
A '
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 5o teet iand -ward in
square feet or acres:
i� f• 11 1 h.y L• i.1 _� ._\
• / 11
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): .j-f /7 , rt
s'�'.d.� -; ;;,; �',J�'�i �y�',a�.fL r�h�1GW�• 1ir� � ,n.,�' #r�;t'.�
Owner /Agent's Signature* [15A NCAC 02H .0502(f)] Dater t d•
Agent's signature is valid only if on authorization letter from the owner is provided.
FORM: SSGP 10 -2013 Page 2 of 3

Lake (Full Pond)
Full Pond
Sh- Oreline
jo
wa�a� -off' Gc� � �t
. ......... .
Please agproximpte� sketch the fallowi i onnaflon an this plan
(pfeasaprovide dIntensions for each Rem, suich as IM ft. x lea jqp
1) All proposed Vegetation cle-OrIng. (Provido dimenVans)
IR the F
,2) Locationi of r' rap rill to be placed above Pall Pond aleval' n
3) LOONOTI, of tip rap or fill to be placed belm the Full. Pond elevation
4) Th,010-cation of any proposed stracturas such asbuildingo, retaining
walls, datks, etc.
6) The location of any excavation or cWiodglng belviv the Full Pond
elevation.
61 Location of access corridors.
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EXAMPLE AGENT AUTHORIZATION FORM
Prooertv Leeal Description:
Parcel ID:
Lot No. (if applicable)
Street Address (if applicable): / _-� / %
Prooertv Owner:
Plan No. (if applicable)
Owner Name (print): J`) lq7 1-" C. erh
Property Owner's Address (if different than the above):
' - 1
Owner Signature:��
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The above registered property owners of the above property, do hereby authorize
of
Agent Name Agent Company Name (if applicable)
to act on my behalf and take all actions necessary for the application, processing, issuance and
acceptance of this permit, certification or authorization including all standard and special conditions
attached.
I hereby certify that the above information submitted on this form and application is true and accurate
to the best of my knowledge.
Authorized Agent Name / Company:
Authorized Agent Signature:
Date: � — �. �.1r ....._ •

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