20160051 Ver 1_Shoreline Stabilization_20160113

State of North Carolina
•;T c •:
Department of Environment and Natural Resources
Division of Water Resources
Loli -
Division of Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
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 2 0 1 60 0 5 1
Raleigh, NC 27699-1617 tQ-
I. Applicant Information [15A NCAC 02H .0502(a)1. Owner Information 1 3 2016
Name: _ i DEw
Mailing Address: G5 FFER PERMITTIN
2
Telephone Number: 7 c -'?'SQ- (02JFax Number:
E-mail Address:j and (2 c I&rn �:�, +
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: A/4 ► ke / n . \ I S r"
Compar
Mailing
Telephone Number.% Fax Number:
E-mail Address: Lkt!m.kd.,<- c f= r %�J c, �
Person to receive the Certification Approval: 4J
II. Project Information [15A NCAC 02H .0502(a) & (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 property (where work is to be conducted)
�r`1�/
County: Jcc— Nearest Town: �� N�� ('(TO r t1.
Subdivision name or site address (include phase/lot number): �—
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (in decimal degrees) -5-;-77,7 '/ 7 Longitude (decimal degrees) 9(-,
5. Describe the,5' d use or condition of the site at the time of this application
(residential, ev , c.):
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how
qq hardeff ning of shoreline has been
avoided, or why it is necessary): S /a,:;,,\ h a, C : o, , 2 S * A,Ae
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:
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:
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feat landward to be impacted (number of trees, for instance): 1iC.l'L
Owner/Agent's Signature* Printed Name Date
[15A NCAC 02H .0502(f)I
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Full Pond/
Normal Water Level
SI
Lake
(At Full Pond/ Normal Water Level)
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

Shoreline Erosion.jpg
r
4"
Z—ba
1/4/16, 6:44 PM
about:blank Page 1 of 1
I: 4q
Z—ba
1/4/16, 6:44 PM
about:blank Page 1 of 1