20160911 Ver 1_Shoreline Stabilization_20160923

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State of North Carolina
{J Department of Environment and Natural Resources
DWR 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
IS, T_ I
Three cbpl'es of the application (including attachments) and the applica
Division of Water Resources /
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Applicant Information [15A NCAC 02H .0502(aj]
1. Owner Information
Name:
Mailing Address:
Cav,qc-1.10, NC .2,6a3/j(. 5&3
Telephone Number: Fax Number:
E-mail Address:
2. Agent/ Contact Person Information
fee should be sent to:
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/regulatory/regdocs/Permits/SAMPLE AGENT AUTHO
RIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: r_' Kc t:) T�riA11t .S
Company Affiliation:
Mailing Address:
e c^1 56
5,ev-vdc e - s , L4,1—
Telephone
LC
Telephone Number: `7o-4. 6Pc)-5711/ Fax Number: -70f, 6(-D,
E-mail Address: GhC :S CAW(� G.
Pg15)i oJd5 Y'GAM . V4
Person to receive the Certification Approval: C' �� p_ P)r i d9es
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: Me_CKlep ik�fj Nearest Town: rNCl:us
Subdivision name or site address (include phase/lot number): t ;A/604 o /fel
Directions to site - please include road names and numbers, landmarks, ettcn.: Z 7 7AI
A-
o-k,p
J n ojoy r . f?-fa w r-,�rGC wj ;DdV X;. ✓ LN .
Latitude (in decimal degrees) -05- '1(pY-7117 Longitude (decimal degrees) &• 13y 4P 1
5. Describe the existing land use or conditionof t7'..
site at the time of this application
(residential, undeveloped, etc.): t^c S f� ( AI l
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:
S. Describe proposed work (include dis ussion as to how hardening of shoreline has been
avoided, or why it is necessary): Ah,41i Ze 640, OMVeN
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 normal pool lake level/ Normal Water Level in square feet or acres:
/%1'x3'
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: 171 f X I
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level . nd 50
P"4 feet landward to be impacted (number of trees, for instance):55 r� cc 5
5 �,-s
Owner/Agent's Signature*
3 /n V--, Kc -L C Y
Printed Name
[15A NCAC 02H .0502(f)]
'Agent's signature is valid only if an authorization letter from the owner is provided.
9 M /I
Date
FORM: SSGP 10-2013 Page 2 of 3

Full Pond/
NormaaVgterLe`l
Shoreline
Lake
(At Full Pond/ Normal Water Level)
j
X71
3 1 b e -I 6 uJ
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

DUKE ENERGY INTERNAL USE ONLY:
Date Received: FAF Paid
F� Application Complete
HEP Fund Permit No.
Site ID Close -Out Date
I. DATE OF APPLICATION* (� Permit/Tag #.:
Construction
Application
version 14p
Duke Energy Lake Services
Mail Code EC12Q
526S '
26S. Church St.
Charlotte, NC 28202
DUKE
ENERGY...
11. APPLICANT INFORMATION (applicant mailing address and contact information)
Name"' —' E 1 PrimaryPhone*
Address* CjNr/cr Secondary Phone
City" �.�< iGLS State* Zip Code' 631-(� 03 Fax Number
Email*
III. PROPERTY INFORMATION (location of permit)
Address* 0 t-ie"DI w L — County* / CCK eA) h krq
City" 19v -W i 45 State* t • 'I Zip Code* O County Parcel ID number
(e.g. Pin, Tax ID, TMS /O �/� 7
Lake*: 0 r m Ail Number...)
Subdivision G CN;N 5L Q. Lot(s) %�-r Plat Book/Page 1-7
To enter the Latitude and Longitude of the property, please use a Latitude (e.g. 35.12345)* 7 6 7117
service/software to easily acquire the location information. Values
should be provided in Decimal Degrees format (35.1245). D
example service: http://itouchmap.com/fationg.btm Longitude (e.g. -80.12345)* 0 3
IV. PROPOSED ACTIVITY
(' New/Modification of Existing Structure C Maintenance of Existing Structure Is Dock
Xedification of Existing Shoreline Stabilization C Maintenance of Existing Shoreline Stabilization
Covered?(ew
New/Modification of Existing Structure & Stabilization ( Maintenance of Existing Structure & Stabilization # of Slips
(' Transfer of Ownership ( Other (please describe below) # of Jetports
Area over land (sq ft) I I Area over water (sq ft) I I Total Square Feet
Shoreline Stabilization (feet) Length of Distance From Shoreline i7e4 �/� _' r �
rr�
Stabilization /¢� r
Materials
Brief Description
of the Activity
We
l,r,51411 Va
Describe Briefly the Existing
Structures Over Land and
Water (include sq ft)
`j 6 Wt W)te Coal r Ale

V. Dock Builder or Engineer
Name/Company I r� trtt�l14 G3 �l?rYi'« sr LLC—
Address
LL
Address 1(38 11/)A Yrldq C- T;i-rM
Phone Number 7b7•4o6,0•
city OBrCS✓c/�t State W7i Zip Code gi��5- Email CSC.4KJ-41Is 1V
C4
Vl. Checklist of Required Documents (to include with Application Submission) �l
,decent Survey (stamped/signed by a professional licensed surveyor showing the location of the existing or proposed
!-i structure and/or survey of the existing or proposed stabilization)
[Photos along property shoreline and photos of any existing structures and/or stabilization in or near the water
❑►KApplication fee (check only, payable to Duke Energy) Signed User Agreement Letter
['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.
Vill, Directions by Road
r7 % �� � ftvoov ' 6'rw a 00'v
Directions by � 0/� I�.� �'��n/ rlN 6AIAMr/ PON t YGetil
Road*
IX, 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 Fdirli
PO Box 1006/ EC12Q
Charlotte, NC 28201
I agree that the information contained within is accurate: \ c

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