20151180 Ver 1_Shoreline Stabilization_20151109

Division of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H.0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10 -2013
SiniofeTin�e Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
1.
Division of Water Resources
401 & Buffer Permitting Unit LNO 1617 Mail Service Center 2 0 1 5 1 1 8 0 9 20
Raleigh, NC 27699 -1617 15
DENR_ MIA
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Applicant Information 15 : F!rAC 02 l .05022 a)J,
Owner
Name:
Mailing
Telephone Number: 041 e?Lj __112/��Fax 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:
P1f,. +Sc�ltil.t's3ce.ar im" ioil/ 0rta;5/ 59IGOCS /r" g!-'.1- or %1 %-,-gd - WPermiL /SAMPLE AGE_N 1 , U T H
R i T!0H FOR,' r f) must be attached if the Agent has signed this application form.
Name:
Company Affiliation: '+
Mailing Address:
Telephone Number: Fax Number:
E -mail Address:
Person to receive the Certification Approval:
II. Project Information MA NQ8.0 02,11.050-,11a), & (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 pr "perty here work is to be conducted)
v� � Nearest Town: "ro��cY� /E'C
County:
Subdivision name o 'tea ress ( Aclude phase /lot number):
Directions to site - please include road nam sand num s, marks, etc.:
Latitude (in decimal degrees) Long' de (decimal degrees)
5. Describe the existing land use or condi ' n of the si .I time, of this application
(residential, undeveloped, etc.):
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as o how hardenin of shoreline ha been
avoided, or why it 's necessary ): /
r
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 pooVake level/ Normal W r Level in square feet or acres:
r' .
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water L el and 50 feet land -ward in
Cquare feet or acres: Z Zze
12. Please describe the vegetation above the normal
50 feet landward to bg ifnpacted (number_qf trees,
ke level/ Normal Water Level and "
rte):
Owner /Agent's Signature Printed Name
Agent's signature is valid only if an authorization letter from the owner is provided
FORM: SSGP 10 -2013
Date
Page 2 of 3

Full Pond/
Normal Water Level
Shoreline _ S
La ke
d/ Normal' dater Lev-=I,'
F
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
I
FORM: SSGP 10 -2013
Page 3 of 3
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