20160555 Ver 1_Shoreline Stabilization_20160531

Department of Environment and Natural Resources
'DWR Division of Water Resources
Division of Water .Resources 1SA NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
PAI®
Three copies of the application (including atiM, ments) anelthp application fee should be sent
to:
2.
Division of Water Resources
401 & Buffer Permitting Unit 20 1 60 5 5 5
1617 Mail Service Center FlrltAl
Raleigh, NC 27699-1617 3 t 2Q1�
Applicant Information [15A NCAC 02H .0502(a)l
Owner I
Name:
Mailing
Telephone Number: %Uig- %U- 700 3 Fax Number: _ff
E-mail Address: ��✓!l �3� �/A-ff00-Cdr,
Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
httr)://www.saw.usace.army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATIONA /FORM.pdf) must be attached if the Agent has signed this application form.
Name, [Vwgvq L Mr -0-10--e
Company Affiliation:
Mailing Address:
Telephone Number: TORI qQ568'5& Fax Number:
E-mail Address: V r'YV'G `/ , Gcdkh
Person to receive the Certification Approval: /%Crw*-
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

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.
I 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: iylow+ dPfttirY Nearest Town: PIT, Gae%elcz
Subdivision name or site address (include phase/lot number): &%or41 ✓ S AoreS
Directions to site - please include road names and numbers, ndlandmarks, etc.:
MoAP9 fuk& 73! & Pile 13ridgv- frit r�
�'i a►o 5tvira,� r►•,►� �-+� �r+c�nc�,ld skclnos rd. J-krk-._
Latitude (in decimal degrees) N 30 %S' C6 7 . Longitude (decimal degrees) G� + oy''Volr
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): 47Uo e7r% -4t, / 6%, - LaaS�-
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
M
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:
�S e u�v.- wall 1I be ec� rpw%%t
ID eh
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 level/ Normal Water Level and
50 feet landward to be impacted (number of trees, for instance): 40 D�rs�s we tl
I,, r- rhav ccl �r�5 b SMIL; bei1l) deine.
Own / ent-s ure* [15A NCAC 02H .0502(f)l Date
'Agent's signature is valid only if on authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCIUMON:
LOT N0. ;09?J PLAN N0. PARCEL ID: 6 J 77 O to 7 3R-73
,
STREET ADDRESS: 30 C?&.04Ci slew� rd.
V
Please print:
Property Owner:
Property Owner:
L*e-�t F1,k
The undersigned, registered property owners of the above noted property, do hereby authorize
AlWom 111A46(Contractor /Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this pit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
37 to,-L)w1m
Telephone:
Gancvrd %V6 2SCIr
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
orized Signatlure
Date:
,L, /-/- -o Z-e..,�
Auth ed Signature
Date: `0 — ( /
d

����D .J� Vii/j " � �e � rd \/d��l 7 L7L" �V 4�lys'✓ti ���1 ' i�"�
�jd3,is� 09 cvzeB -T r, +
i
?,"' l
'.3 ✓a. �sJ�:J�� 9 i54'! � �..rt_, _:� ham... . , a �
�• � �_� i f F _ � { ,�� ;��;p � �� � �� ���\ \\ .�`� \ U N'L � _` o ��� 10 C�_ l �_ G� ��SY�at�� JI� `� ai:� � � ��� � �+-,
r tiJ
61 w bn Ta,
ilM
0

FL
Norma
SI
Lake
(At Full Pond/Normal Water Level)
i
1+U1T
P .c•�i�w�
Please approximately sketch the following information on this plan (provide d� en6sions for each Wc&h
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

Disclaimer: The information contained on this page is NOT to be construed or Approx. Scale 1:1388
used as a survey or legal description. Map information is believed to be accurate
but accuracy is not guaranteed 0 116 ft 232 It
Attr butes at point: 1678448 547891
Layer: Fire Districts
Name: Tillery
Layer: Townships
Name: PEE DEE
Layer: Proposed Voting Commissioner's Districts
District: 1
Layer: Zoning
Zoning: Residential 1
City:
Layer: Voting District Precincts
Name:PEE
Layer: Watersheds
Class: WS -IV
Name: Lake Tillery
River Basin: Yadkin
Layer: Parcels
PIN:
6574 08 87 3873
PinNoDash:
657408873873
CwnerID1:
25866
Name _1:
FINK EDWARD T
Name 2:
AND OTHERS
Name -3:
C/O KEITH B FINK
Addr_1:
537 WILHELM PL NE
City:
CONCORD
State:
NC
Zip:
28025
HouseNum:
309
StrName:
EMERALD SHORES
StrType:
RD
PhyAddress:
309 EMERALD SHORES RD
Deed Acre:
0
TaxDistDes:
LAKE TILLERY FIRE
TownshipDs:
PEE DEE (LAKE LOTS)
VolFireDes:
FIRE DS LAKE TILLERY
NeighDesc:
EMERALD SHORES WATER
Legal_1:
EMERALD SHORES
Legal_2:
LOT 20; M/C, S/1
Legal_3:
EMERALD #20 M/C S/1
DeedBook:
244
DeedPage:
742
DeedYear:
1990
TransDate:
19900101
SalesAmt:
150000
Saleslnstr:
LINK
QufiCode:
Z
LandASVCur:
238317
ImpMajASVC:
128639
ImpMisASVC:
7544
TotASVCur:
374500
LandUse YN:
N
ApprCode:
01
ApprCdDesc:
RESIDENTIAL
ClassCode:
1
ClassCdDes:
RESIDENTIAL
YearBuilt:
1988
Grade:
C
FinishedAr:
1536
Num Baths:
2
Num_Bedrms:
4
Impr2YrBlt:
0
Mutiplelmp:
001
Attr butes at point: 1678448 547891
Layer: Fire Districts
Name: Tillery
Layer: Townships
Name: PEE DEE
Layer: Proposed Voting Commissioner's Districts
District: 1
Layer: Zoning
Zoning: Residential 1
City:
Layer: Voting District Precincts
Name:PEE
Layer: Watersheds
Class: WS -IV
Name: Lake Tillery
River Basin: Yadkin