20160913 Ver 1_401 Application_20160916

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Division of Water Resources 15A NCAC 02H.0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Four 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 O 1 6 0 9 1 3
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Na me: r3 o Qos
Mailing Address: 3550 3a"% -N b%uv-6-s S�
xC 1'1A 1g
Telephone Number: -33G -A 13-a33s Fax Number: „r JA
E-mail Address: dt world @ '�r►oc;t. 4w c -be . co -
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.armv mil/Portals/59/docs/r-r_4atory/r-eynors/Penrn s/.SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must
be attached if the Agent has signed this application form.
Name: Cor'eV
Company Affiliation: 0161A e r p r y Dawes Coots ywc*ion
Mailing Address: _� 1'111 Hess i e D'qn i e I Q o/
Tox�arc� n -C. -.?6714
Telephone Number: 33G -5o3 -73,20 Fax Number: 3-: 6-5 9 9 -5;;95
E-mail Address: oo tt. z e Acids tma; • Cdr✓t
Person to receive the Certification Approval: Corey Doi LP To
I1. 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 pr"f'l, P k , impervious surfaces,
FORM: SSGP 10-2013 VI) Page 1 of 4
STaR� W T R QUALITY
PERMITTING

etc.), rip rap, excavation or dredging below Full Pond/ Normal Water Level elevations,
and construction access corridors. You may use the diagram provided atthe end of this
application form.
I 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: Per 5 o ✓l Nearest Town: -5e nm o r q
Subdivision name or site address (include phase/lot number): rRt5',rue
4b+ a5
Directions to site - please include road names and numbers, landmarks, etc.: r I n
l41 ,,.l 4-7 rlor 4-' 44k -c 6q hk on Zjcn Lege( A"IfC 1 Rd
go +v Cnd_ 4-r,ke LelC4- on PiteDorooabA 19s4�e %�(✓ '►d 1/t/
JL'!; I{ Ikc a Ic)c�- i.1 -A, Tje 9-esie of Lash loi- o., F.ro Loi A_,5
If
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Res 'l Ar a Ict
6. Property size (acres): _ 1 • 2-1 Acres
7. Lake/ river/ ocean adjacent to property:, C o 0.1Co
8. Describe proposed work (include discussion as to how hardening) of shoreline has been
avoided, or why itis necessary): ,5_ �ai r4h inn aro doe+ 5%or,e L:,-, r
4 N -i c e- 15' X 1351 old r- i o rap
9. Will work be conducted from land? 0 From water? ❑
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:
406
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: ;� I X 13'5 1 _o r x-10 S r F >!
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): y1 n 4,.., s W; 1I
C
9-11- /6
Owner/Agent's Signa e' [15A NCAC 02H .0502(f)] Date
'Agent's signature is valid only if an authorization letterfrom the owneris provided.
FORM: SSGP 10-2013 Page 2 of 3

Lake
(At Full Pond/ Normal Water Level)
------I / 00C
P �
R, Rq
Full Pond/ - _ - qL- x 135F4
Normal Water Level low A�zc II Xnci
Shoreline
d 9 � x 133F}
-� g bout 4.11 PC,d
n� Cl,ra�;�5 �
needed IN
IM
L
IU
/ Q.
G°t
1
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.
S. 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

ConnectGIS Feature Report Page. 1 of']
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CONNEwEb
CIG'J 1 / L Person 3ti.t�, !/•O �7 �„e t er v e Printed September 11, 201E
See Below for Disclaimer
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27886 •27887 Parcels
27469
Progress Areas (1)
27888 Progress Areas (2)
27469 Parcel Address Points
•
27469 Parcel Line Dimensions
27885
Lakes
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Roads
Cit, of Roxboro
tlolurtary Agricultural Districts
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S h e J t Feet
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