20160431 Ver 1_Shoreline Stabilization_20160502

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
�. PA1®
Three copies of the application (including attachments) and the applic be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit 2 0 60 4 3
1617 Mail Service Center
Raleigh, NC 27699-1617
D
0 2 23116
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information D" TERF?M)) jf,CES
40
Name: SQr+neS 1 a -v -bee �2c.nna S �tr�je &"13U F RPE MI ING
Mailing Address: Ci 71 to uwy -74L u
Telephone Number: -1 &14 -7q &1 25 15— Fax Number:
E-mail Address: h ar b Ge 1^er2..1`�^-1 q m?,l l • Co YP-)
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 armv mil/Portals/59/docs/reeulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM odf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation: A/,4.
Mailing Address: 1©755 0,/J"-' r4' !V clrwcc,g
Telephone Number: _7r�y-Sl8'S-6'8'S2 Fax Number:
E-mail Address: tww &kul_CA r►s�r&X'011'-% e a MMI
Person to receive the Certification Approval: AlaAh e -.r. 74,,.Lr,- d -
II. Project Information [15A 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 1G-2013 Pagel of 3

b
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: Ab0- r Nearest Town: nils-• &;1 -ea k
Subdivision name or site a dress (include phase/lot number): l20 1�;veey;e.Lo
At. ad 4 C, a&1,U -ha; ito"S6yes 1_0f 11, Ap q
7nam
Directions to site - p eas3eoco include road names and numbers, landmarks, etc.:
�rom NurNood l -t,±,52 -+D 1.�1- on !j 131_ihenleR on 1-i 114sriw Od,
4kr N061frha- L- n Tn:rti_)a..r 511DrrC ..Ciuut-l-ra.ah't" r;V`e+r✓ice iV\
C UV %/.P— ; (ust c sf Spr;,nj000a.ff ')el (Z-Sl;h �OnVc
Latitude (in decimal degrees) Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): ( -e. S d 4 r) -I-; BL
6. Property size (acres): . 33 aa res
7. Lake/ river/ ocean adjacent to property: kcxKe— 1� 114ctA, bJa'le­r4owj,r-
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): R*-,%ovc1 a -_E 91d snc coc l cm.d 6
4-rees 1'1,J- C"rc ei scc-Pt1y i`sswr- .k, Pk D&Y-,
9. Will work be conducted from land? Rr 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:
&V 120' Ssckwaj) ,yc,Gcler, ix,&kLP111 wrP'h.S"r- aj,2 PU4- op -pap lin Fr04
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: MftVel o -F 6 �r"g .d hac,ksill " g«'wc'11
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): krp-&S
2. oc�k 4-rce-5
Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013
J�
Page 2 of 3

SAM PLE AGENT. AUTHORIZATION . FORM .
PROPERTY (LEGAL DESCRIPTION: l p t I
LOT.;NO. ` PLAN NO. i' PARCEL ID: 5
C� 2 ��3 73
STREET ADDRESS: 2 i ver it i -e;j
3,30
Please print:
Property Owner. rel e5,
Property Owner: &r b e y
The -undersigned, registered property owners of the above noted properly,.do hereby authorize
Alac�rC� � � of N4C
,
(Contractor / Agent)" • (Name of consulting firm)
to, act on my behalf and take all actions necessary for the processing, issuance and acceptance 'of
this+permit or certification and any and all standard and special conditions attached. -
'.Property
Property Owner's'Address (if different than property above):' _
�1I 7 �L:"N Ido Kfi'n Nt 2S1,35` `
Telephone: I D `�
We hereby certify the'above information submitted in this•application is true and accurate•to the
best of our knowledge..
Authorized Signature
Auth iz Mignatur e
Date:' Z —1 Date: Le ;

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Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100fr)*: -
1. All proposed vegetation'clearing,
2. Location of rip rap,oefill,to'be placed above the Full Pond/ -Normal Water Level elevation
3. Location of rip rap oyr fill -to be'placed below thefull Pond/, Normal Water Level elevation
4. Location of,any-proposed-structures such as buildings, retaini,ng walls, docks, etc.
5. Location of any excavation oi*edging 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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Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100fr)*: -
1. All proposed vegetation'clearing,
2. Location of rip rap,oefill,to'be placed above the Full Pond/ -Normal Water Level elevation
3. Location of rip rap oyr fill -to be'placed below thefull Pond/, Normal Water Level elevation
4. Location of,any-proposed-structures such as buildings, retaini,ng walls, docks, etc.
5. Location of any excavation oi*edging 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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