20160256 Ver 1_Shoreline Stabilization_20160314

State of North Carolina
0® Department of Environment and Natural Resources
DWR
��
Division of Water Resources
.. __1 C 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 2 0 1 6 0 2 5 6
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
MAH 14 2016
I. Applicant Information [15A NCAC 02H .0502(a)l
1. Owner Information ��
Name: C��iu E CA2LLXt
0LLJQ �LLIyA,"-J
Mailing Address. t 4c15 YCU_010 Okk 72A IL
&Jetbo , l JC. c28761
Telephone Number: 828 584-9g0'/ Fax Number:
E-mail Address: &kLO VAM C P5 18 G AAa( . - CONI
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http:Hwww.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: C L -wt4 ODE CAS- t,S -t LL IyArJ
Company Affiliation: ow"7 2
Mailing Address: 19q-5 YELLOW 1: eek T9A1L
I'Jetbo , MC. a87(ol
Telephone Number: 828)584--9405/ Fax Number:
E-mail Address: 5uLL_t JAN GPS 18 t' GtAALL.. Conn
Person to receive the Certification Approval: GGsEr�N VOA
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: (�Ue V Nearest Town: of
Subdivision name or site address (include phase/lot number):
( 780 --- pt165G 3 — Lor 4A- i �__8
Directions to site - please include road names and numbers, landmarks, etc.:
44 ulv L�o 4o G ,cn V-. Ctocceb t P_T+-( -6 5mp 5,
L%-= PT or -m k-vr-- 'lo , (24HT ONTO 8RADCaeuiAT CE 120
or fro LP4�Dn4o' �0, 0&4r r p s"M Pre= l?. I LWT oaJ a&5oN
Latitude (in decimal degrees) 3S. 7446832ob Longitude (decimal degreesr61. 8Q3722`T06
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): QESr tetITiAL.
6. Property size (acres): - 3, 78 AC2E5
7. Lake/ river/ ocean adjacent to property: L-Akc 7AA4ES
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 61A0( Ml_trJE :jra;�i (- IZ.gTt oM 0jQLV
QoScor�! tJo-rE�
9. Will work be conducted from land? ❑ From water? [r
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:
�,IC�it.clkl2E FT.
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: 140 6QLtA2c- FT -
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):
Noor-
03-io•/(,
Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013
Page 2 of 3
Ito,
° TO

Full Pond/
Normal Water Level
Shoreline
Lake
(At Full Pond/ Normal Water Level)
E^Ctsz tt,� 7�chC
%p (4 op—
oto ,� (ZAp AT 102
C
JEC� CTA�TI cry --�
C'ttA�zc 7
E�eAvATiorS o� t��,iNU
Cu- p,-sb.
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: SSCP 10-2013 Page 3 of 3

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