20160911 Ver 1_401 Application_20160916

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
FOR DUKE ENERGY USE ONLY
Duke File No.
Application Fee S Security Deposits eck #
Date of Duke Energy Lake Services, applicant and/or cttntra+ctoron-site inspection
Date Final Protection/Avoidance Area Markings Field - Verified
Approved to Start Work By * :
Date Completion Required
Date Passed Closeout Inspection*
(Print)
Date of Any Approved Extension
Initials
s
/ g 8
- 1i
Date Recnnv'd Initials
Datc t 161� Initials � Q
Initials
Date
(Sign)
Initials
Any Stop Work Orders or SMG Violations*? (check one) OYes ONo (If Yes, explain in PART V)
Date Deposit Refunded Initials Date Permit Database Updated Initials
* Forward copy of approved application (all pages, plus any attachments that Duke Energy changed) back to applicant
with Approval Letter and highlight any changes. File copies of Approval and Close-out Checklists and any Stop Work
Orders with application.
PART L - APPLICANT INFORMATION (Please Print)
Name_ 1 1 M W T
Lake Address — to a g eA D o I v 1 J/
L C-
Contractor Company
Telephone
Mailing Address
(If di, f -ent)
Contractor Contact Person t f2 !� r ; ( I e- S Telephone -04--
LAKE
LAKE LOT INFORMATION I
Lake f m County e C 4o ( City c� M l S wS State C _ Tax Map No.
Subdivision Lot/ Section No. /e ,� /,Il Lot Sizet W Acres
Are there any Co -Applicants*? (check one) OYes 17No (If Yes, include names, addresses, phone nos., lot nos., lot
sues in PART V — ADDITIONAL INFORMATION) * C -Applicants exist when the proposed work is being done under a
single application, will be performed by a single contractor as one continuous project and is done to benefit multiple owners /
Cn
lease holders of project -front properties within a single development. The check for tate application filing fee and security
O rn 0
deposit should be from the party shown as Applicant and not several checks from the Applicant and Co -Applicants.
� :
m rn
Do not continue the application until an on-site inspection has been conducted between a Duke Energy Lake Services
b
o
co m
Representative (DELSR) and the applicant and/or the excavation contractor. NOTE. Initializing this portion of the
m -0
�
application by a DELSR in no way constitutes approval or eminent approval of the excavation or any other lake use
K D
permbdW activity.
4
t
&Q 16 l U Initials Energy) Vit (applicantleontractor)
z
0
Date of on-site inspection (Duke
Duke Energy Page 1 of 14 rev 9/19/14
Excavation Program
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application 113 10.docx

DUKE ENERGY EXCAVATION PERAUT APPLICATION FORM
PART H. - DESCRIPTION OF PROJECT
A. BASIC INFO
1. Type of excavation: (check one) ! New excavation 0 Maintenance excavation
2. Purpose of excavation: (check one) Access Channel O Water Intake Channel
Wastewater Discharge Channel ❑ Other (spec):
3. Lake user category: (check one)rivate OResidential Marina OCommercial Marina
tublic Other (specify):��Net
n Area Dimensions ft : Length Width ���Dejpth
4. Max. Excavatio ( )
(Note: include additional area dimensions if necessary so response to #5 below equals max" area dimensions in #4)
5. Volume of Excavated Material (TOTAL for the project): � 0 Cubic yards
6. Type of material removed (applicant determines byfield field sample ifpractical): /riLa- ; s � /f
7. Excavation Site area: Acre (s) Disposal Site area n, 10 Acre (s)
8. Total Disturbed Area (including equipment staging area): t9Acre (s)
9. Does the project meet the requirements of the applicable Genal Permit? (check one) Aes ONo
10. Do you claim title to the disposal area? (check one) �(fes ONo
11. Do you claim title to the equipment staging area? (check one) AYes ONo
12. Are there any water -treatment facilities within 50 fleet of the proposed excavation area? (check one) OYesNo
(If Yes, sped y):
13. How will the excavated materi be en Ped and the erosion controlled? (e.g. see attached erosion control plan and
disposal area design):
14. Type(s) of excavation equipment to be used: Y-
15.
15. Will waters or wetlands be crossed in transporting equipment to or from the site? (check one) Oyes 1Aq0
(If yes, explain)
16. Will return water re-enter the reservoir? (Check one) OYes 00 DN/A (If Yes. specify pornt(s) of rre-entry and
show on Excavation Area Drawing)
17. Is them an existing facility (e& pier) that access is being maintained to by conducting the excavation? EDV6 Mo
(If Yes, specify the existing permit number. If No, inchide a scaled drawing ofthe proposed facility). Permit
18. Total planned duration of the work (Include equipment mobilization, excavation through final mitigation measures
complete): START � / �� 1 FINISHrX - / —915
(Month) (Year) (Month) (Year)
Duke Energy
Page 2 of 14 rev 9119/14
Excavation Program
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application 113 10.docx

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
PART 11(Continued)
B. PROTECTION / AVOIDANCE AREA DESCRIPTION
Complete the following table including all land areas within and immediately adjoining the disturbed area:
Identification d `
Protection/Avoidance Areas Agproz. Avoid (Al or Midas -t-0111
(check all that apply) Aea e Field ID Work Area Dwe. ID
a. Marshland, swamp, ponds, beneficial /
aquatic vegetation or other potential wetlands (circle all l/A
that apply)
b. Buffer Zones (spec J& width & sourceTT.;
�i { prt1G
requirement) e
c. Environmental Areas as identified by Duke A
Energy
d. Natural Areas as identified by Duke Energy H
e. Historic properties (spew)
f. Rare or threatened species (specffy) ,!/A
Duke Energy Page 4 of 14 rev 9/19/14
Excavation Program
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DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
Protection/Avoidance Areas
(check all that apply)
Aogra%
Acrease
Identifi tion Method
Avoid (A) or Mitigate (M)
**
Field ID
Work Area Dwe. ID
Buried gas, water, sewer, communications
or electric lines (circle)
Af/ !` d
r
h. Impact Minimization Zones as identified by
Duke Energy
�/A
i. other areas requiring specific avoidance,
protection or mitigation (spec6)
.r J/�
A (�
* For "Field ID" column, specify entity or person that performed the identification and how it was physically marked (e.g. Duke Energy (John Doe)/Pink and purple -dotted tape,
Corps of Eng. (John Smith)/ yellow flagging). For "Work Area Dwg ID" column, show the symbol that is used on the drawings to identify the protection/avoidance area.
** List and attach mitigation plans
Duke Energy Page S of 14
Exca alio" Pro
rev 9/19114
v gram
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DUKE ENERGY EXCAVATION PERNIIT APPLICATION FORM
C. APPLICANT'S SIGNATURES L
Comments: I � 5 .�- 7 cry, C c nl j� c ` �� �! `�(, D' , 4 /11 A /i'�� OT (4c)
nl 1,N .
Applicant Name (print) 1 M W ° l� L_2 L '7
Applicant Signature* W' /
Co -Applicant Name (prim)
Co -Applicant Signature*
Co-Applicaut Name {print)
Co -Applicant Signature*
Co-Applkant Name (print)
Co -Applicant Signature*
Co -Applicant Name (prim)
C04pplicant Signature*
Co -Applicant Name (print}
Co -Applicant Sigeatnre*
i p L. 5w : ,4Z e,4-19-2—
Lot #—
Date F a `t /
Lot #
Date
Lot #
Date
Lot #
Date
Lot #
Date
Lot #
Date
*Per my signature, the information provided in this application is correct to the best of my lmowledge.
BEFORE YOU MAIL. THE APPLICATION TO DUKE ENERGY LAKE SERVICES ENSURE YOU HAVE:
• CHECKED THE INFO THOROUGHLY
• MET ALL REQUIREMENTS FOR A COMPLETE APPLICATION (see cover letter of application package)
• INCLUDE) A SINGLE CHECK TO DUKE ENERGY FOR THE APPLICATION FILING FEE AND SECURITY
DEPOSIT
• INCLUDE) ALL AGENCY PERMITS OR CoMb(ENT LETTERS AND RESOLVED ALL ISSUES RAISED
• INCLUDE) AI.L. REQUIRED DRAWINGS (INCLUDING PROPOSED FACILTnES), PERMIT # FOR MUSTING
FAC MISS, SURVEYS AND PLANS
• INCLUDED COPIES OF DEEDS AND AUTHORIZATION LETTERS
Duke Energy
Excavation Program
Page 6 of 14
rev 9/19114
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application 113 IO.docx

State of North Carolina
Department of Environment and Natural Resources
`= Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources 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
1650 Mail Service Center
Raleigh, NC 27699-1650
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: i C
Mailing Address:1'749-4 d
17r s C �D 1 �a 3
Telephone Number: 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/reRulatory/repdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM. df) must be attached if the Agent has signed this application form.
Name: Ck�J Y ilk c 5
Company Affiliation: C 5-M rl C ` fiP[ e Gtil
Mailing Address: Cv g OA -Kr icj5e — w
inno're sVi V1'r; /V (- X8115
Telephone Number: —Zo�GO • 5-1l ( Fax Number:
E-mail Address: 4C S-ew")Ad5 WiMdST�'�m-
Person to receive the Certification Approval: Ck i /;5V -J'
e-
11.
II. Project Information MA NCAC 02H .0502(a) & (b)1
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 4

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: Meel<(erj Nearest Town: fArAl'C s
Subdivision name or site address (include phase/lot number): lS unl
7o If)A I r -i 1-n/ . C `rw e t+ >~ S, AfC g-80-61 10 14-1 �
Directions t site - please include road names and numbers, landmarks, etc.: -j- N
• ��'
Al �R 4!3 fa nl c�C� man/
At N t' V'- nl ° _142111'`W
Latitude (in decimal degrees) 2 - / Longitude (decimal degrees) - 3 0
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):
6. Property size (acres): .>
7. Lake/ river/ ocean adjacent to property: 4^1
8. Describe proposed work (include discussion as to how har ening of shoreline has been
avoided or whyit is necessary):d� c {-� �' ��
9. Will work be conducted from land? I 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: i
-2/V V -4 hl,
11. Total amount of disturbance (including all clearing, backfill, 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:
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): qr�1-55
w�7
'T,, V/, KLA. L y 9 /al NO
Ownei`/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.
Date
FORM: SSCP 10-2013 Page 2 of 3

FL
Norma
Sl
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
FORM: SSGP 10-2013 Page 3 of 3

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