20151313 Ver 1_Shoreline Stabilization_20151221

State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
Division of Water Resources 15A NCAC 02H .0500 —Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Four copies of the application (including attachments) and the application fee should be sent to:
Division of Water Resources
401 & Buffer Permitting Unit 2 0 1 5 1 3 1 3
1617 Mail Service Center
Raleigh, NC 27699-1617 _ . - ,,..���
7D
I. Applicant Information [15A NCAC 02H .0502(a)] DEC 2 I 2015
DE R 1. Owner Information 440 & 13 ATE R
OFFER PERMSOURCES
Name: David L. Travis (new owner) (old owner Greg Margosian of Raleigh) G
Mailing Address: 5902 Nob Hill Rd., Durham, NC 27704
Telephone Number: [phone]_ Fax Number: n/a
E-mail Address: [e-mail]
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http://www.saw.usace.army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) 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 [15A NCAC 02H .0502(a) & (b)]
FORM: SSGP 10-2013 Page 1 of 4

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,
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: Person County Nearest Town: Semora
Subdivision name or site address (include phase/lot number): Talley Point,
Lot 15 (15 Stillwood Lane) Existing boat dock # 054
Directions to site - please include road names and numbers, landmarks, etc.:
From Roxboro, NC take Hiway 57 NW approx. 12 miles, after crossing hyco Lake the
second time —turn left on Rainey Ridge Rd, take first right on Barefoot Landing Lane,
Then take first right onto Stillwood
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): residential (future) — existing lot
6. Property size (acres): 0.86 acres
7. Lake/ river/ ocean adjacent to property: Hyco Lake, NC
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): RipRock the shoreline, 2+ feet deep, 4-5 feet wide, for
approx. 250 feet length
9. Will work be conducted from land? Y X 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:
FORM: SSGP 10-2013 Page 2 of 4

2 feet x 250 feet, NO modification to the adj. land
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: Little or NO modification, other than RipRock
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):
20 — 30 small trees, and 8-10 larger trees natural landscaping— no grass. There will be very
little disruption to this natural vegetation/landscape
l.?/l7l lois
Ow A' ignature* [15A NCAC 02H .0502(f)] Date
*Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 3 of 4

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NormWater.,
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La ke
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Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ftx 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 4 of 4

ConnectGIS Feature Report Page 1 of 1
4RCO Vi `IEC i GIS Person
Printed October 25, 2015
WES MOStiVG See Below for Disclaimer
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