20160153 Ver 1_Shoreline Stabilization_20160217

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
9Dfvlslon of ..*M Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form 2 0 1 60 1 5 3
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
FEB 1 7 2016
I. Applicant Information [15A NCAC 02H .0502(a)] p -
1. Owner Information F PERWrrms
Name:
Mailing
M e ton w U Z(, U�
Telephone Number: 36"A • ktQ- O VS o Fax Number: 1 - f,'a A- '�;-Oq-�da2.JZ
E-mail Address: __'S \t'd�ocl . Ca w.
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:
E-mail Address:
Person to receive the Certification Approval:
Fax Number:
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)
County: 01 (t C,'-' Ic�cn Nearest Town: )Fc,
Subdivision name or site address (include phase/lot number): y1 b3 N-0 �3 St
S h.v-r r. �1s i or Cl
rections to site - pleas includer1na7rd numbers, landmarks, etc.:
�W [, � � o --
Latitude (in decimal degrees) -'>S , S �3 S� a Longitude (decimal degrees)_:
S. Describe the existing land use or condition of the site at t e time of this applicati n
n
(residential, undeveloped, etc.): s i .� �� h Q To d -t Sk �Q ll
6. Property size (acres): 0 r Lel ? a C r t
7. Lake/ river/ ocean adjacent to property: �-
WAU'"W,
8. Describe proposed work (include discussion as to how hardening of shoreline has been
y necessary): ` l
avoided or why it is necessa < Z� S� rQ0 r D S O vL COwro
9. Will work be conducted from land? V From water? ❑
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake level/ Normal Water
><Iq% CII-� �,S�
e
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 laky level/ Normalpater Level ap 0 feet land -ward in
square feet or acres:
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):6> f Q s S p K ( "
/Agent's Signature* [15A NCAC 02H .0502(f)l
2)
Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Lake
(At Full Pond/ Normal Water Level)
r7 r,
Full Pond \ \
Normal Water Level
Shoreline
a
v
2�e
FI-) �{f or,�
114 `
qa ALoue
CI cite 5'� F6
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

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