20160704 Ver 1_Shoreline Stabilization_20160718

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20 1, 60 7 04 State of North Carolina
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DepartmeWqf1avicanawnteml Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments D ication fee should be sent
to: QV
Division of Water Resources
401 & Buffer Permitting unit JUL 2016
1617 Mail Service Center40Eg-WATER
Raleigh, NC 27699-1617 BUFFER ERM SEG
I. Applicant Information UB'"i". W_�]
I. Owner Information
Name: 0.9)6eZ_ f V0,AtA/4 Z-/?SQN
Mailing Address: ly 4?v _57X_ &"R }> A)W
d Q C4-0 WWA5k_,, AJC Zd-72_R
Telephone Number: JZLN_? /033 Fax Number:
E-mail Address: 455AJZ,1F_Y ca.G % C404n
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
",,v"'
must be attached if the Agent has signed this application form.
Name: 209 /` 4-1Z,Tlaf1
Company Affiliation:
Mailing Address:
.5.
20, 2 0 is 3 0 �6
We ZA 73 �,
Telephone Number:�'1 -7Z� ,Zt/7 Fax Number: d2S -7y3 -6 26 0
E-mail Address: 'a c, .5% 0...0 J. C'o
Person to receive theerti ication Approval: a0/W f4f?77,C_C�,
II. Project Information]
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: 9/9-x° < j 0 N Nearest Town:
Subdivision name or site address (include phase/lot number): /Dd'a
s77<9, 136,e 2V 9/'U, 1U, C �OGo wFl .�C . X72
Directions to site - please include road names and numbers, landmarks, etc.:
AZ0rK11L - HWY /07 TD ?jwf_r_ &&S0C, ,4h o- T
o N11V OzTD tV ON 4A_7F7- 78 �S��i}r�JC3,fr � 12,4 h`lLL �21�
0--1 GST Ty /vim 0^3 121o"W7-
Latitude (in decimal degrees) 1Js,'57__?,9 Longitude (decimal degrees) "gf=3, -YeZ ZZ3
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): �/0�'Ic�,�%% !%aC•�C
6. Property size (acres): _ % fi i¢6Z -c_
7. Lake/ river/ ocean adjacent to property:GC1AL
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): _Tb ST,11614IX4, �fi�oR.EGIN� !v/.<j ;,-
FNM R-fA 27-D6 la -MP 7R -h-:
9. Will work be conducted from land? ❑ - From water?,Z Sfli 6Gl
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:
765-
5 Q �A Cctj ilyC.L-eb o L
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: d�� S C2 Bp c/I� Fuw ibo L
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): APXV0191,
Owner/Agent's Signature* [!--:� 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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Please approximately sketch the following information on this plan (provide dimensions for each
item, such os 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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