20160776 Ver 1_Shoreline Stabilization_20160805

201 60 776
State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
"Dlvlslon 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) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
52
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information 1. _ _
Name:
Mailing Address:
Telephone Number: //O �/� =�'z/� 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:/Iwww.saw.usace.army.miI/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.0 ) 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:
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 3

f
3.
4.
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 of the property (where work is to be conducted)
County: r Nearest Town:
Subdivision nameAr sjW addrQss (include phase/lot number):
Directions to site - please include road names ;�iyl numbers, landmarks, etc.:
Latitude (in decimal degrees) Longitude (decimal degrees)
5. Describe the existing land use or condition of the sathe me of this application
(residential, undeveloped, etc.):
6. Property size (acres): S d�
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline as been
avoided, or why it is necessary):
,// _ -?
9. Will work be conducted from land? �� From water? ❑
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the no7al pool lake level/ Normal Water vel in s re feet or
ED C0
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal �9,/ol lake level/ Normal Water Lev,and 50 et land -ward in
square feet or acres: ��
12. Please describe the vegetation above the normal pool
50 feet landward
(n
I
ake level/ Normal Water Level and
instant ):
Owner/Agent's Signature Printed Name
[15A NCAC 02H .0502(f)]
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013
Date
Page 2 of 3

•...1
Normz
S
La ke
(At Full Pond/ Normal Water Level)
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
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FORM: SSGP 10-2013
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