20240195 Ver 1_Site Plan_20240201

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
1"Vo N Resoa� es ISA NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM. SSGP 02-2017
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the 9PV11c_at1qn_feq 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 Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information [15A NCAC 02_U ,0,5 pa Ua]
1, Owner Information
Name:
Mailing Address:
Telephone Number:
E-mail Address:
A!Ve (n '-T e
309 J�M[ I,co J?=d
_i�V'dgyfo, h& 2IC21-4
Fax Number:
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter must be attached if the Agent has
signed this application form. (A form can be downloaded here:
hgP!9s v says �asaa egmy�rn�iiftrLals/59 doesLrcmulatory .LegdoLsPerTL,;LSAMPLE AGEN-LAUTHOMZ
_
ATION ±Q&Mpdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
B. Project Information [15A NCAC 02.b_„0502 aL& 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, 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 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: _1�Nearest Town: Roxbolv
Lake/ river/ ocean adjacent to property: H\,(,o L lLq,
Property size (acres):
Subdivision name or site address (include phase/lot number): _30" Koolk
Hy6o r-co,
Directions to site - please include road names and numbers. landm;irkr, Atr
K ft Q'I K HuCk
Latitude (in decimal degrees) 36 -.'�q �09" I Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
I
(residential, undeveloped, etc.): cep'," , m 4 o-, i
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
7. Will work be conducted from land? 0 From water? F-I
S. Total amount of impacts below the normal pool lake level/ Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc,) in square feet:
ynv ��4;0 U-22 W,6(
Temporary impacts in square feet:
C9
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
aye- )e,,e i
Temporary impacts (temporary clearing, construction corridor) in square feet:
0
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):
C
Vmrtl dea� Uee
FORM: SSGP 02-2017 Page 2 of 5

11. Signature
Owner/Agent's Signature
Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
12. Please approximately sketch the following information on this plan and provide dimensions A
each ite7p.
a. All proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ 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.
e. Location of anv excavation or dredatyiTff-hr4i
FORM: SSGP 02-2017 Page 3 of 5

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Plan View
FORM: SSGP 02-2017
Page 4 of 5

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