20160632 Ver 1_Shoreline Stabilization_20160624

PAID 20160
AGENT AUTHOZATI FORM
`32
Property legal description
Lot No. Plan No. Parcel ID: c1►`►-�,p 1�$
Street Addr`ss
Property
The undersigned, registered property owner of the above noted property, do
here y authorize
of c1�
Contractor/ agent ' Business Name
To act on my behalf acid take all wtions necessary €o r rhe Wising
issuance and acceptance of this permit or certification and any and all
standard and special conditions attached.
Property owner's address (if different from above):
Telephone `W -
We hereby certify the above information submitted in thi
1 1
and accurate to the best of our knowledge.
uthorized Signature
Date: 3 2.C) I
Authorized Signature
Date:

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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
Four copies of the application (including attachments) and the application fee should be sent to:
Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
I. Applicant Information [15A NCAC 02H .0502(a)1
1. Owne; Information
Name:S �C' ���e`.r1
Mailing Address: \�c&-ALp-�1elP
C_:;
Telephone Number AtA 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:
http://www.saw.usace.army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORMdf) must be attached if the Agent has signed this application form.
Name: ►M r�-yj�-,r1e
Company Affiliation:
Mailing Address:
u
Telephone Number:'?:ON�GN ALall Fax Number:
E-mail Address: 6"3�e V-t0n k ir1 e.
Person to receive the Certification Approval: ;m IESrcor
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 4
O

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: C't1eLy\er,�y rQ Nearest Town: Q. -Y ce_
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.:
oN+�o �¢,c��Q�1. e.S Q\ _,,.i.�
5. Describe the existing land us i or condition of the site at the time of this application
(residential, undeveloped, etc.): e -',�
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property: �cxk- e-
8. Describe proposed work (includes discus s'on as t how hardening of shoreline has been
avoided, or why it is necessary):
9. Will work be conducted from land? ❑ From water? [ell
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:
I1r-JI ,r "I _ I ---t lh
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: ala►Nj X 4 = qcx(\ V�-
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):
ii
Owner/Agent's Signature* (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

41
Fi
Normi
S
Lake
(At Full Pond/Normal Water level)
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ftx 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
I ItMpQC,S \ �C`G� •b►"�. 1"1 V: �w r _ Ot'1 \ �]��4�p�r1 +f�� \S
���� `-ta \mac es3 ►�bo ��,.
51 H \p
FORM: SSGP40-2013 Page 3 of 3
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