20160602 Ver 1_Shoreline Stabilization_20160616

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: 5SGP 10-2013
Shoreline Stabilization Application F PAI
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Applicant Information [15A NCAC 02H .0502(ag
1. Owner Info
Name: IV I I' o
Mailing Address:
X80 ;-7
28160602
1(L
Oe �r
Telephone Number: 7042111 5140 Fax Number:
E-mail Address:
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
htto://www.saw.usace.armv.mil/Portals/59/docs/resulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.Ddf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Person to receive the Certification Approval:
11. Project Information 1`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.
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--ta eA Nearest Town: T oA ria n
Subdivision name or site address (include phase/lot number): 130 S{ e �` •rid �r
rt(O SNA I/C C.S 16 6
Directions to site - please include ro'a'd names and numbers, landmarks, etc.:
0Cl S �a�R ��' e �' on mprr.svn 'VW)
Latitude (in decimal degrees) W. 0- Longitude (decimal degrees)_- g0.9a �M'
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): L) n,} Vd 6, t
6. Property size (acres): 1,01-)
7. Lake/ river/ ocean adjacent to property: a �,t Vor-r^,vn
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): a4�+1_na no lq agf%L ievtL
9. Will work be coo--nducted from land? 00' 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:
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: 760 s a 4
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to be impacted (numberv of trees, for instance)::
.
,-eLs 165 4 "N 5 '%C, 4 ,a 44617
Owner/Agent's Signature
P.WL".J oa,/),, ► x/7116
Printed Name
[15A NCAC 02H .0502(f)l
"Agent's signature is valid only if an authorization letter from the owner is provided.
Date
FORM: SSGP 10-2013 Page 2 of 3

Ft
Normz
S
La ke
Please approximately sketch the following information on this plan (provide dimensions for each
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.
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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