20160374 Ver 1_Shoreline Stabilization_20160418

State of North Carolina
Department of Environment and Natural Resources
D_. 0, k W. 6.
Division of Water. Resources
,R
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 2 0 1 6 Q 3 7 4
1617 Mail Service Center PA
Raleigh, NC 27699-1617 $
I. Applicant Information [15A NCAC 02H .0502(a)] 4AR �8 �
1. Owner Information
Name: John Freeman
Mailing Address: 4316 Woodwind Street
•
Charlotte, NC 28213 �,NO
Telephone Number: 704-576-4861 Fax Number:
E-mail Address: [e-mail]
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
' 2 U n :1

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: Montgomery Nearest Town: Mt Gilead
Subdivision name or site address (include phase/lot number):
Swift Island Plantation Lot #7
Directions to site - please include road names and numbers, landmarks, etc.:
From Albemarle NC—turn onto NC 24E/27W/73W and travel approximately 5 miles
Turn right onto Lilly's Bridge Road Go approximately 1 5 miles and turn right onto
Plantation way (entrance to Swift island) Lot 7 will be on vour right past Timberlake
Court
Latitude (in decimal degrees) 35 16 32.0 Longitude (decimal degrees) -80.05 14.8
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): residential
6. Property size (acres): .72 acres
7. Lake/ river/ ocean adjacent to property: _ Lake Tillery
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): clearing shoreline and placing class 2 Rip Rap
9. Will work be conducted from land? ® From water? ❑
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:
221 linear feet of shoreline x 6' of grading below full pond —1326 sq 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: 221 linear ft of shoreline x 8' of grading above full pont —1768 sq 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): 3- 6 trees
March 24, 2016
Ow r/Agent's Signature [15A NCAC 02H .050ZIf1) 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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