20160935 Ver 1_401 Application_20160916

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 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 2
1 6 935
Raleigh, NC 27699-1617
Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: L I Si
Mailing Address:
2
Telephone Number: (%2,8 7y3 -7 55 Fax Number:
E-mail Address: w;ll �c,.m_4�e�,4ncs5oc�ate:
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
httr)://www.saw.usace.armv.mil/Portals/59/docs/reizulatory/reRdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: Z r _<�n n 's
Company Affiliation: B TSnA'S
Mailing Address: (' -15 a k1U.>j i
Telephone Number: (fj2sl 7y3-33vy Fax Number: Nig) ?y3 330
E-mail Address:6r�i-4,-k�r�
Person to receive the Certification Approval:
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: SAc,k scw o Nearest Town: C.H -�,ttt f gs
Subdivision name or site address (include phase/lot number): �i0 'fA MALA iRAiL
LT ti � 9 ZAt4 Ac.A S ttnP c S c , 613 , r t
Directions to site - please include road names and numbers, landmarks, etc.:
[v SI.C�r u? -PitifCFitK I TUX to (-Z-FT QtJ1CN,►an'?,'TQf. RQ Ga Q
Tu ti LIFT CpWro c whir -D -i MTgJ. ilLmL it_�Lf•T" ogayo TAi4r4L A-rltf*1L
V. L t
Latitude (in decimal degrees) 35. I y �� R'7 Longitude (decimal degrees)_M_11 3 .171303
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): $IL-ssXkf t,,33 SAL_
6. Property size (acres): I , 01 AcRi.S
7. Lake/ river/ ocean adjacent to property: L A x i- C�Ls.r i v i L -LL
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): NtLtSSAR`A sC 5AVIL Tltz S1k:>t4 LI VOL
Lji Puiw 10 1 H AND i -A-/ PARZK, twLt4 pup KAP M050 Fr
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:
y00 so; Z.C.-
11.
..S
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: 2� 4-, r2L_,A R F_ FU_r
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): Zr
I -
/Agent's Signature* [15A NCAC 02H .0502(f)]
q1z 16
Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013
Page 2 of 3

CLfARl.O
AaA��5c�
Full Pond/
Normal Water Level
Shoreline - <
Lake
(At Full Pond/ Normal Water Level) DOCb(in1Q
I -1X12 DocK
y7L3o ? fft f— ?
I
L o -e U'39
;L%,o NAHRLA "ffrtR%L
VU1V R ftp FT
yr)( 50
��KSOF-T
H6ov£ ir/ATQ,
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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PNEPANEL BY
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YEI.I(M MotINTAIN RVAU-P.0.00X :.L•1
CAS"IERS,NORTII rARMINA
TEL. 704-74.1 J1130