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Home My WebLink About20151159 Ver 1_Shoreline Stabilization_20151105D-W R Dhdslon of Water Resources 15A NCAC 02H .0500 - Water Quality Certification, - Shoreline Stabilization FORM: SSGP 10 -2013 Shoreline Stabilization Application Form ElvED Three copies of the application (includiki chments) and the applicatioAQYA XX y sent to: DENR -LAND Division of Water Resources 2 O • STORMWATER PERMITTING' 401 & Buffer Permitting Unit 1 5 1 1 5 9 1617 Mail Service Center Raleigh, NC 27699 -1617 State of North Carolina Department of Environment and Natural Resources Division of Water Resources I. Applicant Information [15A NCAC 02H .0502(a)] *1. Owner Information Name: MC, C\L-, Mailing Address: 0 P i rte, L 2 C v s f C;�. ►��g4 Telephone Number: i0`t -U46l -3[Q77 Fax Number: E -mail Address: IoCi u%oDdGIGtV�£� �p` . Go�� 2. Agent/ Contact Person Information J A signed and dated copy of the Agent Authorization letter (a form can be downloaded here: - htto: / /www.saw.usace.army.miI /Portals /59 /docs /reeulatory /repdocs /Permits /SAMPLE AGENT AUTH• ORIZATION FORM. df) must be attached if the Agent has signed this application form. Name: gP Company Affiliation: r Mailing Address: y tooaQ22d , Nr, 25 /2A Telephone Number: 70q- q37 -0b1 6 Fax Number: %N -tf5-q -00 �(Y E -mail Address: llohi Wu 154fea l Person to receive the Certification Approval: /her%" 11. Project Information [15A NCAC 02H .0502(a) & (b)j 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, i i 6#-Ko n d / grmal V aterI I Sho elite Lake (At Full Pond/ Normal Water Level) 15-0 F�- � 3 F-f 1-3'�o'j 3 ff P bvvc, r Rip A bL0 C : I L CrN r `B t (ow 9Mj4i 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 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: Nearest Town: Subdivision name or site address (include phase /lot number): -Ls Q F- NN i 5 u. I a- Directions to site - please include road names and num 3 I. rP-,q Iuc tee, I vv landmarks, etc.: c �� ►0uAz_ 4--, Latitude (in decimal degrees) 3.5-, 2 1 LI 8 6 % Longitude (decimal degrees)_j?D , 00 22 % 8 5. Describe the existing land use or condition of the site at the time of this application (residential, undeveloped, etc.): ka `, clew +% a 6. Property size (acres): tiZ�2_ /�_ c. 12 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): 0 L' `w L s q b i V 1 �, 1' 0 N 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: 1 SD �f Xf 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: % ro F-1- i 3 Ei YSS) � � ;-1--Z �t,�ip�r X/� RIO 12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 500 feet landward to be impacted (number of trees, for instance): ' Owner /Agent's Signature Date Agent's signature is valid only if an authorization letter from the owner is provided. FORM: SSGP 10 -2013 Page 2 of 3 SAMPLE AGENT AUTHORIZATION FORM PROPERTY LEGAL DESCRIPTION: -7 LOT NO. PLAN N0. PARCEL ID: CSTREET ADDRESS: 09,0 Lf11 i n l Please print: Property Owner: (TV, (-Y, )Dn J i,<, Property Owner: X L-.Gr 1 OCA C ;S The undersigned, registered property owners of the above noted property, do hereby authorize D l��i -t�l . ' ►�+� of L4-81d-e- alvka GTD ►' S (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): -7 D M Telephone: '4 -7 0 `i -(WI --;�(o .7_T 'A C 9-73Lf � We hereby certify the above information submitted in this application is true and accurate to the best of our knowledge. .Z W4�2 � Authorized Signature Date: %' 7—) ,s- Authorized Signature =�-- -- Date: q - a l I. 11/2/2015 Montgomery County, NC Print Map 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: 6575 15 53 0758 Neighborhood: PEE DEE Total Value: 86100 Full PIN: 657515530758 Legal 1: PENINSULA AT LT Land Use: N Name 1: MOSES BRANCH & CO LLC Legal 2: LOT 1 Appr Code: 13 Address 1: PO BOX 1267 Legal 3: PENINSULA AT LT #1 Appr Desc: FAST FOOD RESTAURANT City: ROCKINGHAM Deed Book: 614 Multiple Imp: 000 State: NC Deed Page: 300 Zip: 28380 Deed Year: 2008 Road Name: CRAIN Transfer Date: 20080201 Road Type: CT Deed Acres: 0.41 Tax District: LAKE TILLERY FIRE Sale Instr: WD Township: PEE DEE QufiCode: N Vol. Fire: FIRE DS LAKE TILLERY Land Value: 86100 Attributes at point: N: 553808, E: 1675048 Fire Districts I Townships Proposed Voting Commissioner's Districts Name: Tillery Name: PEE DEE District: 1 Zoning Voting District Precincts Zoning: Residential) Name: PEE City: Watersheds Class: WS -IV Name: Lake Tillery http: / /aregis. webgis .neUnc /Montgomery /printable.asp 1/2