20160062 Ver 1_Shoreline Stabilization_20161119

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Shoreline Stabilization Application Form 2 0 1 60 0 6 2
Three copies of the application (including attachments) and the application fee
should be sent to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
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• Applicant Information [15A NCAC 02H .0502(x)] t
1. Owner Information
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Name: r_hr- s vas; l i ou _ ,°. 9'WATEFr rpcc: a
Mailing Address: 0771 _�Cig �.cQomr� 1c.
_?;, L,esL_, MD Z08-1?
Telephone Number: 30)-2oll- y9ol1 Fax Number:
E-mail Address: Cvas1l'ou l0to y,ti,A;l, 60Y-,
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/SAMPL
E AGENT AUTHORIZATION FORM.pdf) must be attached if the Agent has signed
this application form.
Name: CLa-,,se kX
Company Affiliation: C&--Jsor% 1 t le
Mailing Address: ES -o5 Fre 4,, ?�P.
CILovt,0 S -CG. Z01 -7 10
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Telephone Number: 'sd3- £s31- 9-3h, Fax Number: s a3 -8a l -SCS SS
E-mail Address: gc(P­/53Y�eex, c4 -►,13 n�_ • . --
Person to receive the Certification Approval:
• Project Information [15A NCAC 02H .0502(x) & (b)]
• 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.
• 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.
• Attach a photograph of the shoreline/ buffer proposed to be stabilized.
(Include a scale of some sort- a yard stick, shovel handle, etc.)
• Location of the property (where work is to be conducted)
County: (7G154-0'-� Nearest Town: _ie(m-o�,-
Subdivision name or site address (include phase/lot number): 1_o+ 3/
McZEc­1 4�roPe_1 -4 5L V, Vi s i o✓x
Directions to site - please include road names and numbers, landmarks, etc.:
7-a ke w y_r 149 4odc2 ! ►24 On 4o 274 , 4 -ay -c -
On
/`��r1h1 //Ole 1-,p —,,
vLsk Loi- ( 44ous_e_*-M
Latitude (in decimal degrees) S� " Longitude (decimal degrees) �Sl
• Describe the existing land use or condition of the site at the time of this
application (residential, undeveloped, etc.): VcLc.a� l o 4-
• Property size (acres): e & Acr'_s
• Lake/ river/ ocean adjacent to property:
2

• Describe proposed work (include discussion as to how hardening of shoreline
has been avoided, or why it is necessary): Qe..,r a- 2 po!p k
�7g' Sbcorel���e _ S�aaN �lac� c,Lass `3 ro Baa c,�l�rq Skorel�►.�.
All r,,b,Ts (t«,& ut b rr.Q
• Will work be conducted fro land. From water?
• 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.^ ��3'L� ��• %3 "X 17Yr)
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:_
C0v9 3 x /7g J- 9"-x /7% aee-055 j-ek.,
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): Maao6W e�- S,,AaU <,rA "cc, i y i"s"�, k �� /2')
i�
Owner/Agent's Signature' [15A NCAC 02H .0502(f)l Date
'Agent's signature is valid only if an authorization letter from the owner is provided.

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•-- = _-= C'Sz.crB_:h.- P.!Ic:cac'k R�:.trPc:�f
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Home tri;trt
Despn=nim3!ix;
Sfidt Slwb Rtwrr ':ler: laselfieht
El
Past!
cy-tleIide - ..-IDelete
h0b*Vd
. . . r . . . _ . . ; . . . -r . . -.- . . . r . . _
F
Lake
(At Full Pond/ Normal Water Level)
Full Pond/
Norma�Wa� Leno vel
Am
Shoreline
rx
9`tI g
M&4 of 'Office mems' ,
13 b -fl
r1o�-vim
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Please approximately sketch the following information on this plan (provide
dimensions for each item, such as 10 ftx 100 ft)*:
• All proposed vegetation clearing
• Location of rip rap or fill to be placed above the Full Pond/ Formal Water Level
elevation
• Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level
elevation
• Location of any proposed structures such as buildings, retaining walls, docks, etc.
• Location of any excavation or dredging below the Full Pond/ Normal Water Level
elevation
0

o Location of construction access corridors
5

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 31 PLAN NO. PARCEL ID:
STREET ADDRESS: 30CI rC�2 s+ �l a ce
�belo�a X.C. Z-3-012
Please print:
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
of /i�t , /L �fri/;n5 rLly�tS�y�`�''�/�1`L
P(C-'=ntractorjgent) (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):
� esda ,)/i ,? F-/ 7
Telephone: 301- A 11 - 9 40 4
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorize�Signat�ure
Date:
Authorized Signature `
Date: /

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