20160162 Ver 1_Shoreline Stabilization_20160219

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Division of Water Resources
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State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
12RE )6L /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
1650 Mail Service Center v v
Raleigh, NC 27699-1650
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: q L'k mac.
Mailing Address: 1 5 ate 'SA-dt,ag '\ }:417�m ,
Telephone Number. Fax Number:"10t�— -Si _ _;�-q 5
E-mail Address: k otq►'k � k - Cc,Ifl
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
t+tt_: wv v�.sa�ti+.usace.arrr�y.n,i!/F�nrlalsJS ccs regufatory/regdocs Perniits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: +0 _ttN- vJ e- 5
Company Affiliation: C-(-bC-- Or f z f
Mailing Address: 6-66 �KY�c� t I— �ri'►1 vJ
Telephone Number: I FaxNumber: '70+.666- 5-1 61
E-mail Address: C�)Lt>� A'Ja I [5 K) I ►J45TY-Y_ A vn , tyi 4—
Person to receive the Certification Approval: „ C_h rIJ riG�gc 5
IL Project Information [15A NCAC 02H .0502L0_L_#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 locations of
vegetation clearing, structures (buildings, retaining walls, docks, impervious surfaces,
FORM: SSGP 10-2013
Page 1 of 4

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: r - Q Nearest Town:
Subdivision name or site address (include phase/lot number):
I.5 409 ffax) �&Ct ° GO _?fl i w5
Directions to site - please include road names and numbers, landmarks, etc.: T77/4 k qx,- i 26� W`^
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):
6. Property size (acres): V."
7. Lake/ river/ ocean adjacent to property:
KC /V 11)rM
S. Describe proposed work (include discussion as to h//ow hardening of shoreline has been
avoided, or why it is necessary): c\Y- c ci ci o r GA- E %; cc; (f_55
9. Will work be conducted from land? 1% From water? 0
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:
�o" o4- *An,. ( &I ( too o_)
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 feet landward to be impacted (number f trees, for instance):SS
C see. rn 6 s
I - 113 - 206
Owner/Agent's Signature* [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 2 of 3
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Please approximately sketch the following in. ; � L pian (provide dimensions for each
item, such as 10 ft x 100 ft)*: m
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

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
FOR DUKE ENERGY USE ONLY
Duke File No.
Application Fee $ Security Deposit $ Check # Date Recv'd Initials.
dOCMDate of Duke Energy Lake Services, applicant and/or contractor on-site inspections Date (w - t t i ems; Initials
Date Final Protection/Avoidance Area Markings Field - Verified
Approved to Start Work By * :
Date Completion Required
Date Passed Closeout Inspection*
(Print)
Date of Any Approved Extension
Initials
Initials
Date
(Sign)
Initials
Any Stop Work Orders or SMG Violations*? (check one) ❑Yes ❑No (If Yes, explain in PART V)
Date Deposit Refunded Initials Date Permit Database Updated Initials
* Forward copy of approved application (all pages, plus any attachments that Duke Energy changed) back to applicant
with Approval Letter and highlight any changes. File copies of Approval and Close-out Checklists and any Stop Work
Orders with application.
PART 1. - APPLICANT INFORMATION (Please Print)
NameM66,5 401 6 -IM � K"OTI Kyo i A Telephone
Lake Address I 4 t)0 I `J 7 "tTcw RA • Mailing Address � � r�G'C' �Z"�`tti° � r � � m en
�'
Ai (If different)
V'' t� r? I i ►� _s , C L I C'U 'r Al e- GI ST /VC )- �-43
Contractor Company
r/ ))� IN�orrc5t.�: Ili, N,
Contractor Contact Person R �l , KeAK 7 K Telephone ( )
LAKELOTINFORMATION / 1 (
Lake i C �ry M County a Je0i ► k r City �{ hF� L State f+ i' Tax Map No.
Subdivision" � a �e Lot / Section No. %_,'+ S Lot Size Acres
Are there any Co -Applicants*? (check one) ❑Yes ❑No (If Yes, include names, addresses, phone nos., lot nos., lot
sizes in PART V — ADDITIONAL INFORMATION) * Co -Applicants exist when the proposed work is being done under a
single application, will be performed by a single contractor as one continuous project and is done to benefit multiple owners /
lease holders of project -front properties within a single development. The check for the application filing fee and security
deposit should be from the party shown as Applicant and not several checks from the Applicant and Co -Applicants.
Do not continue the application until an on-site inspection has been conducted between a Duke Energy Lake Services
Representative (DELSR) and the applicant and/or the excavation contractor. NOTE. Initializing this portion of the
application by a DELSR in no way constitutes approval or eminent approval of the excavation or any other lake use
permitting activity.
Date of on-site inspection L) Z_ 11 1 L-0 Initials (Duke Energy) (applicant/contractor)
Duke Energy Page 1 of 14 rev 9/19/14
Excavation Program
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application 11 3 10.docx
-1-8I17

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
PART II. - DESCRIPTION OF PROJECT
A. BASIC INFO
1. Type of excavation: (check one) New excavation ❑ Maintenance excavation
2. Purpose of excavation: (check one) *—Boat Access Channel ❑ Water Intake Channel
❑ Wastewater Discharge Channel ❑ Other (specify):
3. Lake user category: (check one) *nvate ❑Residential Marina ❑Commercial Marina
❑Public ❑Other (specify):
$c 6 0 3
4. Max. Excavation Area Dimensions (ft): Length %J5 Width i o 0 Depth .3 — C:HAA'N,i—
(Note: include additional area dimensions if necessary so response to #S below equals max. area dimensions in #4)
5. Volume of Excavated Material (TOTAL for the project): _t OD Cubic yards
6. Type of material removed (applicant determines by field sample if practical): 151#_
7. Excavation Site area: C • it Acre (s) Disposal Site area: C . /0 Acre (s)
8. Total Disturbed Area (including equipment staging area): G , lqc Acre (s)
9. Does the project meet the requirements of the applicable General Permit? (check one) L<Yes ❑No
10. Do you claim title to the disposal area? (check one) [Yes ❑No
11. Do you claim title to the equipment staging area? (check one) L les ❑No
12. Are there any water -treatment facilities within 50 feet of the proposed excavation area? (check one) ❑Yes P(,No
(If Yes, specify):
13. How will the excavated material be entrapped and a erosion controlle 9 (e. see attache erosion control plan and
disposal area design): �3A�'�� ��Arl G(Sl �7 � � ee— dt; L e5S
r
14. Type(s) of excavation equipment to be used: %J " �- �� ' IK ID icn/� w�'eq
15. Will waters or wetlands be crossed in transporting equipment to or from the site? (check one) ❑Yes Vo
(If yes, explain)
16. Will return water re-enter the reservoir? (Check one)
show on Excavation Area Drawing)
❑Yes *No ❑N/A (If Yes, specify point(s) of re-entry and
17. Is there an existing facility (e.g. pier) that access is being maintained to by conducting the excavation?I Yes ❑No
(If Yes, specify the existing permit number. If No, include a scaled drawing of the proposed facility). Permit �#
18. Total planned duration of the work (Include first equipment mobilization, excavation through final mitigation measures
complete): START G.% / C) / 4, FINISH 0 7 / I �•
(Month) (Year) (Month) (Year)
Duke Energy Page 2 of 14 rev 9/19/14
Excavation Program
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application 11 3 IO.docx

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DI.IM ENERGY EXCAVATION PERMIT AIBPUCATICIN FORM
C. APPLICAIvT'S_SIGNATURES
Cormments:
Applieant Name (print),� (01L
Applicant
Co -Applicant Name (print)
Co -Applicant Signature; _._._._.._____
Co -Applicant Name
Co -Applicant Signature
Co -Applicant Nance
Co -Applicant Signature _..__----__.__��-------.----
Co-Applicant Name (print)
Co-Applicant Signature*
Signature*
Co -Applicant Name
Co -Applicant Signsture*
Lot #
Date
Lot # _
Date
Lot #
Date
Lot #i
Date
Lot #
Date
Lot #
Date
'Per my signature, the information provided in this application is correct to the best of my knowledge.
BEFORE YOU MAIL THE APPLICATION TO DUKE ENERGY LAKE SERVICES ENSURE YOU RAVE:
• CHECKED THE INFO THOROUGHLY
• MET ALL REQUIREMENTS FOR A COMPLE------ MMINN (see cover letter of application package)
INCLUDED A SINGLE CHECK TO DUKE ENERGY FOR THE APPLICATION FfLrNG FEE AND SECURMT
DEPOSIT
INCLUDED ALL AGENCY PERMITS OR COMMENT LETTERS AND RESOLVED ALL. ISSUES RAISED
« INCLUDED ALL REQUIRED DRAWINGS (INCLUDING PROPOSED FACILITIES), PERMIT 4 FOR EMSTING
FACILITIES, SURVEYS AND PIANS
INCLUDED COPIES OF DEEDS AND AUTHORIZATION LETTERS
Duke Enerpv Page G of 14 rev 9119114
EXCavallon Program
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application 113 1 Q.docx

L\J 1-� 11lJIV IV) /1f -
NO SCALE
CRAIG L. LONG P.L.S.
753 DALIERE DRIV
CORNELIUS, N.C. 28031
[phone]
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DUKE ENERGY DIRECTIONS BY ROAD
Lake Use Permit Applicants and contractors: Ease of locating the proposed project site can
have a big impact on permit processing time. Please complete this form and return in along with your
completed permit application to:
Duke Energy
C/O Lake Services – EC12Q
P 0 Box 1006
Charlotte, NC 28201-1006
1-800-443-5193 and select Option 5
Applicant's Name:_Mansukhlalm Kothadia
Street Address (at Lake) _15409 Jetton RD
Subdivision Name:–
Tax Parcel ID (if known): -00133178
City:_Cornelius
State: NC
Latitude: 35.4702
Telephone
704-902-5445
Lot (s) 5_
County,Mecklenburg
Zip:_28031
Longitude: -80.9432
Directions from major road or highway):
1-77 North to exit 25 – West on Catawba Ave Right on Jetton Rd –
DESCRIPTION (Garage, white fence, mobile home, etc)
15409 Jetton Rd I�Io�� e 14 be �; e

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