20160621 Ver 1_Shoreline Stabilization_20160621

State of North Carolina
® 1 60 6 2 1 Department of Environment and Natural Resources
Division of Water Resources
" Dlvislon of Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
p�11D Shoreline Stabilization Application Form
Three ce 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(a)]
I. Owner Information
Name:
Mailing Address:
Telephone Number: (� — %,a(; 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/regulator(/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM pdf) must be attached if the Agent has signed this application form.
Name: 44 OP, '(i r,
Company Affiliation:
Mailing Address:
Telephone Numbe(q:/l, ��{-�S [>.�_ Fax Number:
E-mail Address: C l 'q ./�.•-�.
Person to receive the Certification Approval:
II. Project Information [15A NCAC 02H .0502(a) & (b)]
I. 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

3.
4.
5.
1.1
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.
Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale
of some sort- a yard stick, shovel handle, etc.)
Location 9 e property (where work is to be conducted)
County: Nearest Town:
Subdivision name or site address (include phase/lot number):
ions to site - nlease include road names and
bers. landmarks. etc.:
Latitude (in decimal degrees) �, ;� Longitude (decimal degrees) —' 6 �, P
Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):
Property size (acres): ii , / C (� re -'s
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discu
ssion as to how hardening of shoreline has been _
avoided, or why it is necessary): � ::(�, /J /G i,S
9. Will work be condu4d from land? ❑ ?
rom water.
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake vel/ Norm I Water Level in square feet or acres:
l
11. Total amount of distur ance (including all clearing, back f(I, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Nor m% Water
/Level and 50 feet land -ward in
square feet or acres: 1
12. Please describe the vegetation above t -e normal pool lake level/ Normal Water Level and
50 fe t landward to be impacted (number of trees, for instance):
1 i11A Y I > /^ J__
oDy(.c /Ler
,C;
Owner/Agent's Sign4)re4 [15A NCAC 02H .0502(f)l Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM. SSGP 10-2013 Page 2 of 3

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