20151029 Ver 1_Shoreline Stabilization_20191002

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Ir
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
istvD lon of Water Resources 15A NCAC 02H .0500 - Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10 -2013
I
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee shouQd Ike genet 02
to:
Division of Water Resources 2
401 & Buffer Permitting Unit 0
1617 Mail Service Center ED
, 0
Raleigh, NC 27699 -1617
I. Applicant Information l'15A NCAC 02H .0502(a)]
Owner Information
Name:
Mailing Address:
Telephone Number: Fax Number: /v/A
E -mail Address: JC_kS � �rr\a (? C-c) f'n
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 /reRulatory /regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION F,O_ IRM.pdf) must be attached if the Agent has signed this application form.
Name: /��" 1)Y,"O-Kc'
Company Affiliation: �})►^��� (�crns�i- u�ii�n
Mailing Address: X0755 w � ��' dam% rte` INV,y- r 4 N
Telephone Number: 704'Cfgf God Z- Fax Number:
E -mail Address: vna-lwh� c �,�sl•c '
Person to receive the Certification Approval: IVa�� / A nic"'`d
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.
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) I
County: S } " �y Nearest Town: lvorwcoc
Subdivision name or site address (include phase /lot number):
4c,42, &LJ. %i 1 i'-o v [3
Directions to site - please include road names/ and numbers, landmarks, etc.:
/T�v'y SZ X, �r %Voru.,00d , r i �{ /�t� o-r fv " v-C4
or.N rigO ctr,46 kake! /lei 4,
Latitude (in decimal degrees) Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): 00cLu tOD-6d *s c, bcwtf k_)Ust�
6. Property size (acres): m S ,
7. Lake/ river/ ocean adjacent to property: �C k_e_
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Add. a Sro'w c.-1' fa
51c bc.I I zG s %u re tf i ►t e
9. Will work be conducted from land? VT 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:
excCkvC.tiCF?. / b��k3�ll /s��,,,till . 3' �C50� = ISO "s,?, -Y,/-
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: rcmcVd cif fwu lei nr- 1`r>✓cS l on c Swc- ��qus►�
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): 3 vee�S
q�z3��s
Owner /Agent's Signature* j15A NCAC O2H .O5O2(f)l 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:
LOT N0. 137 PLAN NO. PARCEL ID: �t5(4o4gA413+
STREET ADDRESS: Got 1 -14 Lake #e-" iQOa?dQ
R Ono e) A, NC, awlas
Please print: �f
Property Owner: \ I n,r1k5
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
/I/aj in /) /rxoytc , of XLUrcl �S�Y�i1yr
(Contractor / 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):
2OOscsC Pl ►S Roa r � c-us i K� v2�C�1r
Telephone: 7D4 36 f — 416o 2
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Date: v /%/
Zthorized Signature
Date: 912— 3/ / 5

Ful Pond/
Normal ater Leve
IM 7��
Shoreline
Y
La ke
(At Full Pond /Normal Water Level)
I
. i
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
3,
FORM: SSGP 10 -2013 Page 3 of 3

ConnectGIS Feature Report Page 1 of l
This map is prepared for the inventory of Real Property found within this jurisdiction, and is compiled from recorded deeds, plats and other public records and data. Users
M the map are hereby notified that the aforementioned public primary information sources should be consulted for verification of the information contained on this map.
The Stanly County Geographic Information Systems Division of the Office of Information Technology assumes no legal responsibility for the information contained on this
map. Also, when the deeds and or plats are viewed for a parcel, the Stanly County Register of Deeds Office makes no guarantees regarding the collection, accuracy,
authenticity, or use of these records. The web site is for informational use and convenience only. The Register of Deeds shall in no way be held responsible for errors or
omissions in these records nor for any actions resulting from their use. The official records are kept in the Stanly County Register of Deeds Office. To view deeds on this situ
you must install the AltemaTIFF viewer. To install, please visit http: / /www.altematiff.com/install ie/ II
http: / /stanly. connectgis. com /DownloadFile. ashx? i=_ ags_ mapfc9802435c074bdeacea2b3df... 9/28/2015
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