20240010 Ver 1_Site Plan_20240102

State of North Carolina
il
Department of Environment and Natural Resources
t
zl� Division of Water Resources
I1 ate? -Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 02-2017
Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing - hvw1e- C'w IVI li ljw-
b. Location of rip rap or fill to be placed above the Full ond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc. no")�
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
{A�'�•, -,+"�'�'+i'�7z+r,"�'2f'rk'F'���rw'x`3'#'�;;F-r �y-rt,�z.��3 lY P, .Atf., ..t*rt���3., aµ' y,+e '`x
Lake
(At Full Pond/ Normal Water Levelj "',11
Full Pond/ Normal -late sieve
Shoreline
Plan Vie
Mae
FORM: SSGP 02-2017
Page 1 of 3

FORM: SSGP 02-2017 Page 2 of 3

State of North Carolina
il
Department of Environment and Natural Resources
t
zl� Division of Water Resources
I1 ate? -Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 02-2017
Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing - hvw1e- C'w IVI li ljw-
b. Location of rip rap or fill to be placed above the Full ond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc. no")�
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
{A�'�•, -,+"�'�'+i'�7z+r,"�'2f'rk'F'���rw'x`3'#'�;;F-r �y-rt,�z.��3 lY P, .Atf., ..t*rt���3., aµ' y,+e '`x
Lake
(At Full Pond/ Normal Water Levelj "',11
Full Pond/ Normal -late sieve
Shoreline
Plan Vie
Mae
FORM: SSGP 02-2017
Page 1 of 3

FORM: SSGP 02-2017 Page 2 of 3

State of North Carolina
il
Department of Environment and Natural Resources
t
zl� Division of Water Resources
I1 ate? -Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 02-2017
Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing - hvw1e- C'w IVI li ljw-
b. Location of rip rap or fill to be placed above the Full ond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc. no")�
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
{A�'�•, -,+"�'�'+i'�7z+r,"�'2f'rk'F'���rw'x`3'#'�;;F-r �y-rt,�z.��3 lY P, .Atf., ..t*rt���3., aµ' y,+e '`x
Lake
(At Full Pond/ Normal Water Levelj "',11
Full Pond/ Normal -late sieve
Shoreline
Plan Vie
Mae
FORM: SSGP 02-2017
Page 1 of 3

FORM: SSGP 02-2017 Page 2 of 3

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 37 PINNO,
PARCEL ID: 21736246
STREET ADDRESS: _17901 Wilbanks Drive Charlotte NC 28278
Please print:
Property Owner: _Cameron Douglas_
Property Owner: Tiffany Douglas_
The undersigned, registered property owners of the above noted property, do hereby authorize
_TODD FLOWERS_______--, of _LAKE WYLIE DOCK CONSTRUCTION LLC
(Contractor J Agent) (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):
SAME
Telephone: _410-353-0223
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge,
Owner(s)
Signature
Date: 1 6 C X-2-5
f
Signature -- —_-------
Agent Lake Wylie Dock Construction
Signature:�
Dater
Date:--L-) 0 '1 j o)3-------