20160821 Ver 1_Shoreline Stabilization_20160822

r � 216082
State of North Carolina
fixit 112
Department of Environment and Natural Resources
Division of Water Resources
Division of T0196
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 � 2@20 WED
I. Applicant Information 15A NCAC 02H .0502 a ] AUG 2 2 2016
1. Owner Information �[ DEQ -WATER RESOURCES
Name: LLC--," (W,¢vr �4A*5 401 & BUFFER PERMITTING
Mailing Address: —,;,,O •8Y- 015 (
5iV-'te5""11" N G11697
Telephone Number: 7AD T73 • 7 PO O Fax Number:
E-mail Address: �-f 5 U n-, LS 4'5 v+��-S 12 �es,l �Sd-*- -z . G 0 rM
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
htt : /www.saw.usace.army.mil/Portais/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTHO
RIZATION FORM.gdf) mu t be attached if the Agent has signed this application form.
Name: ,�j,'r�a
Company Affiliation: __056 5invG s e C
Mailing Address: rF /�
/%1,90 res Wile IAI C _-7W//.
Telephone Number:%O S/! �prPO -5 Fax Number: D
E-mail Address: s (,v� . ,
Person to receive the Certification Approval: nnLdq CS
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, etc.),
rip rap, excavation or dredging below Full Pond/ Normal Water Level elevations, and
FORM: SSGP 10-2013 Page 1 of 3

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: Y'e_" Nearest Town: �GCeTlili��✓
Subdivision namVpr site address (include phase/lot number): �w;Ali��/GS
6 n'tr7a / A-AflD
Directi ns to site - please include road names and nu erg I�ndmarks, etc.:.Z
36 "04 CAI 7e.,r lice, P-oti 5T -A -rt -
P -76 N 11 1 �l C&yy- C4 • . GO (1 �I u► e� oN i �rCA I—Al• : /0'
Nd
DN AoINf Q
Latitude (in decimal degrees) 510 509D 1 S Longitude (decimal degrees)
S. Describe the existing land use or condition of th site at the time of this application
(residential, undeveloped, etc.): ✓dC_ Y,
6. Property size (acres): _ *, 7J1-
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discu sion a�to how hardens g of s7ovvew
eline has be n
avoided, or why it is necessary): S bA-/' 2e, S r�(i ,t/'G 7e
Y05 f0 A/
9. Will work be conducted from land? � From water?Lo
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the •n� l pool lake �evel/ Normal Water Level in square feet or acres:
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pop? lake Ipvel/ Normal Water Level and 50 feet land -ward in
square feet or acres: 0o i(
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50I
feet landward to be impacted (number of trees, for instance): � �-� A ;d
Owner/Aerf�'s Signature*
Crp 619 , LLc
"r1/nti.es
Printed Name
115A NCAC 02H .0502(f)
'Agent's signature is valid only if an authorization letter from the owner Is provided.
Date
FORM: SSGP 10-2013 Page 2 of 3

Lake
(At Full Pond/ Normal Water Level)
Full Pond/ o b e o a o BOA ©ae
Normal Watn evel 60000 l� 6) ��o o 6
Shoreline
� soca
9r b
Please approximately sketch the following information on this plan (provide dimensions for each
item, such os 10 ft x 100 ft) *:
I. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
I 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

DUKE ENERGY INTERNAL USE ONLY: Construction DUKE
Date Received: FAF Paid Application
F �j ('
Application Complete "`nppP " . `ORGY
HEP Fund
Permit No. Water Strategy, Hydro Licensing and Lake Services
Duke Energy
PO Box 1006/ EC12Q
Site ID Close -Out Date Charlotte, NC 28201
I. DATE OF APPLICATION*PermiVTag
It. APPLICANT INFORMATION (applicant mailing address and contact information)
Name*– A zA LLc Primary Phone* V� ,.7 _7Q0JD� -
Address* D Secondary Phone JJ
City' 7)%i / t State* ©, Zip Code* (O�� Fax Number --�
Email" � 7 5",45 6AA46:3 r6'/e_.51�L� t celn
Ill. PROPERTY INFORMATION (location of permit)
Address* /�Q �/ j/� �cj /1%— County" e
City" yv 1M4V State* Zip Code* 8%�0 ( County Parcel ID number
Lake*:(e.g. Pin, Tax ID, TMS q&39157 77�-
Number...)
Subdivisio Mljld�C4�°SbN/�Dlrl'�bot(s)E:jV= PlatBook/Page �v'�3 7
To enter the Latitude and Longitude of the property, please use a�7
service/software to easily acquire the location information. Values Latitude (e.g. 35.12345)* s
should be provided in Decimal Degrees format (35.1245). �--•–/ C���
example service: httpJ/ttouchmap.com/latlong,html Longitude (e.g. -80.12345)*
IV, PROPOSED ACTIVITY
(modification of Existing Structure ( Maintenance of Existing Structure Is Dock
ew odification of Existing Shorelin St ilization (' Maintenance of Existing Shoreline Stabilization Covered?
i' New/Modification of Existing Structure & to i ization (–Maintenance of Existing Structure & Stabilization # of Slips F]
(' Transfer of Ownership C Other (please describe below) # of Jetports u
Area over land (sq ft) Area over water (sq ft) Tota[Square Feet
Shoreline Stabilization (feet) Length of Distance From Shoreline�i OW N
Stabilization �00
Materials Ir
Brief Description
of the Activity
Describe Briefly the Existing
Structures Over Land and
Water (include sq ft)
e_

V. Dock Builder or Engineer
Name/Company
Address
f
L r� rm.1&1,Phone Number -6V161-1
�1J J1
City Me n,5 J'i f c State Zip Coder q %' Emai�4C�����5
a o nye ^VG�
VI. Checklist of Required Documents (to include with Application Submission)
iecent Survey (stamped/signed by a professional licensed surveyor showing the location of the existing or proposed
[tructure and/or survey of the existing or proposed stabilization)
Photos along property shoreline and photos of any existin structures and/or stabilization in or near the water
[/ Application fee (check only, payable to Duke Energy) Signed User Agreement Letter
[+(J Applicable local, state, and federal permits ❑ Plan and profile drawing showing all measurements and elevations
❑ Habitat Enhancement payment (if applicable)
VII. Approval Process
• Application is reviewed and determined if complete. Fields with an asterisk are required,
• If application is not complete or does not include all items and information listed in the checklist, the
application will be returned as incomplete.
• A Duke Energy representative will visit the site to conduct a visual inspection.
• Applicant will be notified of approval or denial.
• Applicant is to have the notice, to be supplied by Duke Energy upon application approval, posted and
must be viewable from water. The notice must remain posted until a representative inspects the
project and determines the project is complete and within the application specifications.
VIII. Directions by Road
X77 N fv t-56 Woo fes_ -i s � ,� 0� 4�-
Directions by o5lrA L PAYiC l 1--1,A1 r`A! CCDv-eS 0- eo/i �Alt�� '0 A/
Road" /
L-Wd l 4 -Al
M. Application Submission
Please complete, print and sign this application. Then enclose all items from the checklist above in an envelope and
submit all the information to the address below.
Water Strategy, Hydro Licensing and Lake Services
Duke Energy Print Form
PO Box 1006/ EC12Q
Charlotte, NC 28201 , , /
I agree that the information contained within is accurate: /M v

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