20160304 Ver 1_Shoreline Stabilization_20160328

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: 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
Raleigh, NC 27699-1617
I. Applicant Information [15A NCAC 02H .0502(a)j
1. Owner Information / r
Name:
Mailing Address: _
9
20160304
MAR 2 8 2016
Telephone Number: 9.S—,_.?max Number:
E-mail Address: N
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:
11. 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 propert(where work is to be conducted)
County: Nearest Town: i�c
Subdivision narpe or sit address (include phase/lot number):
Directions to site -please include road names andgambgrs, landmarks, etc.:
Latitude (in decimal degrees) Longitude (decimal degrees)
5. Describe the existing land use or condition of thepte at he time of this application
(residential, undeveloped, etc.): r
6. Property size (acres): ,--5-- S
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as
avoided, or,
9. Will work be conducted from
r
From water? ❑
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake level/ Normal ater Level in square feet or acres:
/� /lir -
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water Le I and 50 feet land -ward in
square feet or acres:/' -
12. Please describe the vegetation above the normal pool Irke level/ Normal Water Level and
50 feet landward to bei cted mber of tr , for ' tance):
i C w�
Owner/Agent's Signature Printed Name
[15A NCAC 02N .0502(f)]
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013
Date
Page 2 of 3

Full Pond/
Normal Water Level
Shoreline
La ke
(At Full Pond/ Normal Water Level)
7
I
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.
S. 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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