20160353 Ver 1_Shoreline Stabilization_20160411

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
FOR DUKE ENERGY USE ONLY
Duke File No.
Application Fee $ Security Deposit $ Check # Date Recv'd Initials
Date of Duke Energy Lake Services, applicant and/or contractor on-site inspections Date 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) OYes 13No (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) bac
with Approval Letter and highlight any changes. File copies of Approval and Close-out Checklists and a
Orders with annlication. P
PART I.-- APPLICANT INFORMATION (Please Print)
Nara—�` 64 \JJE 11 R i JC t4 Q
Lake Address I O % CTD ld ew I ON D I^I S -
ri�
Telephone
Mailing Address
(If different)
Contractor Company 0 f tnw.- ` Pe -c- iN4 638e)A-Kc'&r_rArM ►V100rcV6 I[C.Nt �glls
Contractor Contact Person _ C (�15r-icli t"S Telephone �J 66 O . 6_1 I
LAKE LOT INFORMATION 1� q t
Lake 1 �0Y1' A r% County �v-A0 r City KD0vYsJ-tll c_ State Af e Tax Map No.
Subdivision e T Lot/ Section No. (10 +_Lot Size !L
Are there any Co -Applicants*? (check one) 13Yes AgNo (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. Inibial&V this portion of the
application by a DELSR in no way conslit les approval or eminent approval of the excavation or any other lake use
pe"nWng acdvvty.
Date of on-site inspection 3 , 7 (p Initials (Duke Energy) 1 1(applicant/contractor)
Duke Energy Page 1 of 14 rev 9/19/14
Excavation Program
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application 113 l0.docx

DUKE ENERGY EXCAVATION PERNUT 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 O Water Intake Channel
9Wastewater Discharge Channel O Other (specify):
3. Lake user category: (check one) Private ❑Residential Marina OCominercial Marina
OPublic ❑Other (specify):
4. Max. Excavation Area Dimensions (ft): Length 101) Width 4-5 Depth 3
(Note: include additional area dimensions if necessary so response to #5 below equals maxarea dimensions in #d)
5. Volume of Excavated Material (TOTAL for the project): .179 Cubic yards
6. Type of material removed (applicant determines byfreld sample if practical): CI A I � 5
7. Excavation Site area: O •V (c Acre (s) Disposal Site area: D. O k Acre (s)
8. Total Disturbed Area (including equipment staging area): ®. /,;L Acre (s)
9. Does the project meet the requirements of the applicable General Permit? (check one) Yes ONo
10. Do you claim title to the disposal area? (check one) *es ❑No
11. Do you claim title to the equipment staging area? (check one) XYes ONo
12. Are there any water -treatment facilities within 50 feet of the proposed excavation area? (check one) ❑Yes JJNo
(If Yes, specify):
13. How will the excavated erialIle entrapped and the erosion controlled? (e.g. see attached erosion control plan and
disposal area design): e-
14. Type(s) of excavation equipment to be used:!�_ W .4 I 0 A!Q r -C" e4CC� 14 r
15. Will waters or wetlands be crossed in transporting equipment to or from the site? (check one) Oyes o
(If yes. explain)
16. Will return water re-enter the reservoir? (Check one) ❑Yes *o ON/A (If Yes, specify point(,) of re-entry and
show on Excavation Area Drawing)
17. Is there an existing facility (e.g. pier) that access is being maintained to by conducting the excavation? lklYes Mo
(If Yes, specify the existing permit number. If No. include a scaled drawing of the proposed facility). Permit # 1 0 SS
18. Total planned duration of the work (Include first equipment mobilization, excavatio through final mitigation measures
complete): START Q_ / 16 Fimm o 7_
(Month) (Year) (Month) (Year)
Duke Energy Page 2 of 14 rev 9/19/14
Excavation Program
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application 113 10.docx

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DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM '
C. APPLICANT'S SIGNATURES p 1
Comments: 1 (4 AJj j:;e- JC 178 /1"l
Applicant Name
Applicant Siguat
N.v-t c, Pc krsoA/
„ Z 3 5 4eA rvvw-,rct "• (bf S
Lot # �6
Date
Co -Applicant Name (pririt) Lot #
Co -Applicant Signature* Date
Co -Applicant Name (print) Lot #
Co -Applicant Signature* Date
Co -Applicant Name (print) Lot #
Co -Applicant Signature* Date
Co -Applicant Name (print) Lot #
Co -Applicant Signature* Date
Co -Applicant Name (print) Lot #
Co -Applicant Signature* 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 HAVE:
• CHECKED THE INFO THOROUGHLY
• MET ALL REQUIREMENTS FOR A COMPLETE APPLICATION (see cover letter of application package)
• INCLUDED A SINGLE CHECK TO DUKE ENERGY FOR THE APPLICATION FILING FEE AND SECURITY
DEPOSIT
• INCLUDED ALL AGENCY PERMITS OR COMMENT LETTERS AND RESOLVED ALL ISSUES RAISED
• INCLUDED ALL REQUIRED DRAWINGS (INCLUDING PROPOSED FACILITIES), PERMIT # FOR EXISTING
FACILITIES, SURVEYS AND PLANS
• INCLUDED COPIES OF DEEDS AND AUTHORIZATION LETTERS
Duke Energy Page 6 of 14 rev 9/19114
Excavation Program
c:\users\ann\appdata\local\microsoft\windows\temporary internet files\content.outlook\mp7eolj9\c-w excavation
application 113 10.docx

State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
Division of Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization 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. -jam
1650 Mail Service Center
Raleigh, NC 27699-1650
I. Applicant Information [15A NCAC 02H .0502(a)1
I. Owner Information
Name: 0�5&1 K/e/Vr/6A
Mailing Address: /0 I ' /deAl A vd ZA-ve
M60V'e-5 WIN, NC X6117
Telephone Number: moo. 1.0511-4 Fax Number:
E-mail Address:�a hJc nici r�C� nle
2. Agent/ Contact
20160353
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http://www.saw.usace armv mil/Portals/59/docs/reeulatorv/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM Pdf) must be attached if the Agent has signed this application form.
Name: 0 k 0 P)W—VIA.
Compai
Mailing
Telephone Number: � (� , S/I / Fax Number: , . 6 60. 5-9 to
E-mail Address: CBC 5e.AWA16 (2 li)1'Al 1 m. Ne
Person to receive the Certification Approval: cko
I1. Project Information L15A NCAC 02H .0502(a) & (b)1
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 e-deJ Nearest Town: bDre_3N-11
1e.
Subdivision name or site address (include phase/lot number): Ck � -C— %o 1(.4-
Directions
6¢
Directions tp site - please include road names a� numbers, landmarks, etc.: �7
t 36 l� otj w I50aN 14P7rMA^1Ce L.N.
de orad i—r�, e_
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): _)Ce- 51 Ae w
6. Property size (acres): 6 -All
7. Lake/ river/ ocean adjacent to property: o -e' Wl ►tnl
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 8reAcat 6AJ A-Cre e
9. Will work be conducted from land? From water?
L 1113,
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake level/ lNormal lWater Level in square feet or acres:
nn X �� X 3
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 levet/ Normal Water Level and
50 feet landward to be impacted (number of trees, for instance):
r
'X
Owne ent's Signature* [15A N C 02H .0502(f)1 Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013�GA Page 2 of 3
`";

R
Norm
5
Please approximately sketch the following information on this plan (provide dimensions for eoch
item, such os 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/ Norma► 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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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: John Wenrich
Street Address (at Lake) _107 Golden Pond
Subdivision Name: --N/A
Tax Parcel ID (if known):_4628929067
City:_Mooresvill
State:
Latitude: 35.6090
Lot (s) 264_
County_lredell_
NC Zip:_28117
Telephone: [phone]
Longitude: -80.9201.
Directions from major road or highway):
1-77 North to exit 36 – West on Hwy 150 – right on Waddell – Right on Hermance – left on
Golden Pond =1st house on Left
Descriptive Structures- (s) ( i.e. brick garage, white fence, mobile home, etc)
107 Golden Pond Lane

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