20160931 Ver 1_Shoreline Stabilization_20160926

3 CG>iGS
State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: SSGP 30-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
2 O 60 9 3
401 & Buffer Permitting Unit
1617 Mail Service Center rvk__@�a
/I n _Raleigh, NC 27699-1617
I. Applicant Information [15A NCAC 02H .0502(a)] SSP 2 ZO
1. Owner Information 40E-WgTF 16
Name: ,fin ���f X (�- •1 ,�i �1.Q w o e�'`F RRFso
Mailing Address: Z2''( IMS c114_
(V\a D��V , k`e i\J L z,Ki
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Telephone Number: v� I Fax Number:
E-mail Address: ctill& a D0,1eVw L�. AP -k c6'"'`
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/regula orregdoclPermitsISAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Person to receive the Certification Approval:
Fax Number:
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

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.
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: �'ZE�'DGLL- Nearest Town: Y*oreSo�1�
Subdivision name or site address (include phase/lot number): Lz-T ZZ ytkCt-tr (\ 1Zg0tJe
[`[q lC2ek- (_A Moores t', I\e 10& ?Y11-7
Directions to site - please include road names and numbers, landmarks, etc.:
c l o 5 V t -A ` t'rC a _-, nn 4c L1t IZP . 1 /1J 1/Z. I ' , [ Q Tart,,. Pi (/ii- C U'\
Latitude (in decimal degrees) 3 S1 y 0'7 Longitude (decimal degrees) �ov. '9'?
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): WS l J04 t 1
6. Property size (acres): s &3
7. Lake/ river/ ocean adjacent to property: Nd rV%'X 6L'%
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): (CA re ro S I0 --k 0'f 5_�Wre
r 1, k%P SAP
9. Will work be con ucted 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:
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: —)'w `- Zw s a 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): - G-, , / t eo 5
'�'" ) S -froth, S„ vv'� V L 2 A
)L�
Own er/Agent`'s�ignature* [15A NCAC 02H .0502(f)] Date
-Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

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Full Pond/
Norma
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Lake
(At Full Pond/ Normal Water Level)
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Please approximately sketch the following information on this plan (provide dimensions for each
item such as 10 ftx 100 ft)*: Q
1. All proposed vegetation clearing
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2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation �U
2t
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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. 0 ,1
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation uilIr
6. Location of construction access corridors tjl rA
FORM: SSGP 10-2013 Page 3 of 3

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