20160624 Ver 1_Shoreline Stabilization_20160623

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
�i
Division of Water Resources 1SA NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 30-2013
Shoreline Stabilization Application Form 2 C, 6" 6 2 4
Three copies of the application (including attachments) and the application fee should be sent
to: 20
Division of Water Resources PAID 1 6 0 6 2 4
401 & Buffer Permitting Unit
1617 Mail Service Center
�o e
Raleigh, NC 27699-1617 JUN
0 2 3 Zpl a
I. Applicant Information 115A NCAC 02H .0502(a)l 6
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1. Owner Information _ FFFRp Soy
Name: dval- 70 -
Mailing Address: 25-17 W ,30MF ,7' Z)IQ
ZL' ?'R'4 fG f
Telephone Number: ( y6 ?qZ S075'Fax Number: 62s,— ?V_? -6001 a
E-mail Address: _fa,6: ¢{,o,7�r ee rv�n,� • cb-�.
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 FORM.pdf) must be attached if the Agent has signed this application form.
Name: o G N
Company Affiliation: C0 07?77N
Mailing Address: __ ,9- O. 130 X 36q
Telephone Number:
E-mail Address:
Person to receive the
Al -C- Ze73L
e9'Z9-Z_ZIo 20V7Eax Number: R7�- ZV3 - G 2_�6 0
Approval: ,907%V %f1/F- /1.30 j// _
II. Project Information 115A 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: c- I -A- eks afj Nearest Town: C7-s#4
Subdivision name or site address (include phase/loth umber):
15�r ScJ,r2/*7,f_R.30Af G J/, C Ze7 2-3
Directions to site - please include road names and numbers, landmarks, etc.:
6f&Hlkx5 /o 71V i o Al- �V0270 n/ e)N G,eeFT To f, ,yl- Cy
�DgF_S7" DN X'/G-/T- 7-0 M15e.SQNC— L oN e -X 1 %6
Latitude (in decimal degrees) 3J , W> 168 Longitude (decimal degrees) 5' _ c � q 7 3 1
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): H 0 r -n L S (TE.
6. Property site (acres): , q 3 ff-C12g—'s
7. Lake/ river/ ocean adjacent to property: -.+CE, 62&9A I%! l,Q�'-
8. Describe proposed work (include discussion as to how hardening of, shoreline has been
avoided, or why it is necessary): Com 9'rr2 UGT A-
S94-w*u, Tb svio ,Foct5771-4- ,C-0201rot-a --t- s�-tEAP-4-- cicr-nr✓ L
9. Will work be conducted from land? ❑ From water? [V
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:
LII 9 S& Jlci &5.' C'0 r.J
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: A129 942 f7-
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'OM K_
,r9LON6- Ab LE dv/ tOA-c. 2 � leg mo V*e_ - SCS
Owner/Agent's
`Agent's signatui
FORM: SSGP 10-2013
re [15A NCAC 02H .0502(f)]
Date
valid only if an authorization letter from the owner is provided.
Page 2of3

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