20160486 Ver 1_Shoreline Stabilization_20160513

State of North Carolina
Department of Environment and Natural Resources
D,WR- Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources
FORM: SSCP 30-2013
Shoreline Stabilization Application Form PAI
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit 2 6 4 4$ 6
1617 Mail Service Center RECEIVED
Raleigh, NC 27699-1617 MAY
ffENA-I.AND QV,g1,ry
cl. Applicant information [15A NCAC 02H .0502(a)] 18i"�
1. Owner information pii
Name: _4A A E
Mailing Address: _ IP13
f�'o ��� �� y G 93 E���� ld Slu,,e,Fs /�'I � Cti`/rel y✓. c'., 2730
Telephone Number: 76-q $7 7 5 9 2 Fax Number:
E-mail Address: r -,A ry ir M be. c -o �''►
2. Agent/ Contact Person Information T
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/reaulatory/reedocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name:0�_
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address: 161141AIZ rJ'"QS�YQ�t Ae�
Person to receive the Certification Approval: LkrP G&Cker
II. Project Information MA NCAC 02H .0502(a) & (b)i
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

r, S

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: 1M 0;v Nearest Town:
L t=pt 6(
Subdivision name or site ad ress (include phase/lot number): t--
Directions
Directions to site - please include road names and numbers, landmarks, etc.:
�-�- w 612 L� Z ? TD 1 � 1-1 L. % TO
Latitude (in dec/mal degrees) Longitude (decimal degrees)
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): 12r5 i /i rrilll i'r'a 1
6. Property size (acres): V = e-C,I? hs 5
7. Lake/ river/ ocean adjacent to property: a KCF-
S. Describe proposed work (include discussion as to how hardenin f shoreline has been
avoided, or why it is necessary): t✓ o 0C) S t7A w C.
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:
3, :5-o :FA- X 3 t
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: X Sb t+ k 3 F -j 7 6-0 s , Fl -
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): S E d E R A )
����►� T12.ESS
S /iG
1 7yz,
Owner/Agent's Signature` [15A NCAC 02H .0502(f)1 Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

W
Ia , later evel
S! re I i n
i
Lake
(At Full Pond/ Normal Water level)
15 D? se, �7i--
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as .10 ft x 200 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

SAMPLE AGENT AUTHORIZATION FORM
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to ac: C1'd zat,� d'! 3CG�."S f;L:tiSSd`j/ yr L"`a UCEi�iilGr u.=IwPce a!'w acc-�; tar of
ttii� p�. r C- ctr'iPca_lor, a, -.d any gild all star•dard and spc-<•al c,%nd;:.,cns at a&ied,
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Date: