20160079 Ver 1_Shoreline Stabilization_20160121

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: SSCP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
1
Division of Water Resources
401 & Suffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Applicant Information [_!_5A NCAC 021-? .0502(a)�
Owner I
Name:
Mailing
2 0 1 60 0 7 9
JAN 212016
s
Telephone Number:%—�-� =5 % ax 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:
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Ong_ 1AT!ON F0 R must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Person to receive the Certification Approval:
Fax Number:
II. Project Information [151b, NCAC 02s0502(a) g: (-'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'oca`o.^.c 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.
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 r perty here work is to be conducted)
County: //l Nearest Town: �odrl
Subdiv' ion name or to address (include phase/lot number):
Directions to site - please include road names avers, landmarks, etc.:
Latitude (in decimaidegrees) 1_64ude (decimaidegrees)
S. Describe the existing land use or condition ofthey' '� e a the time of this application
(residential, undeveloped, etc.): �c/
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include�discussi n as to how hardening f shoreline has been
avoided, or why it is necess;�
9. Will work be conducted from land? PFrom water? ❑
10. Total amount of disturbance (including ail excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake level/ Normal Water Level in square feet or acres:
-11 11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water evel and 50 feet land -ward in
square feet or acres: /,/- = /S�o
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' sta ):
Owner/Agent's Signature' Printed Name
�I C It F.jr AI- 11-!U nc n': l::il
s
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013
Date
Page 2 of 3

La ke
(At Full Pond/ Normal Water Level)
Full Pond/
Normal Water Level
Shoreline j
F (A
i
G
Please approximately sketch the following information on this plan (provide dimensions for each
Irem. sucn as 1U rt x IUU ttl'":
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 or anv or000seu ZL,,aLU,�� 1--.. __
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corri���r�
FORM: SSGP 10-2013 Page 3 of 3

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