20160967 Ver 1_401 Application_20161016

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2 0 1 6 0 9 6 7 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 Stabilize ion Application Form
Four copies of the application (including attachments) and the appli to:
L9 (99;
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Division of Water Resources o
401 & Buffer Permitting Unit OCT 6 2016
1617 Mail Service Center DEQ -WATER RESOURCES
Raleigh, NC 27699-1617 401 & BUFFER PERMITTING
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: ✓11 &w L 4�=r czc ✓ t Sb�—`
Mailing Address:! 1 17
0ttrh00", 2 7-7c)C�T
Telephone Number: ' }—/5 3 i( ,- D V,;. 0 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:/Iwww.saw.usace.army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: r ne �.vr'cn
Company Affiliation: A(A e -n e-, L.E.)mpet-in &-7-; t.
Mailing Address: Tb
* b c t ru , NCL, d -Z_7 9/
Telephone Number: '33/, Fax Number:
E-mail Address:
Person to receive the Certification Approval: 96k r,n-C 4 eQ'-" At ,-1—
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 4

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: Nearest Town: 'SeY-,o!�.�
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.:
—rL.. b✓t to lKcc, ✓7-e--, l�ic�g / 0 ��� ��. �c�l 6� �=' 2
"-7
IF f
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): ?V+'S)'Oce ILEI cam(
6. Property size (acres): I'D • &,9 Q.C,:e
7. Lake/ river/ ocean adjacent to property:4�0 L -e-,
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): t GC's` t,_xx ll
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:
X002 �z� 6C PIC�e-eL�.1 10�-► 1 ` %
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retainingv
walls, etc.) above the normal pool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres: P97 " 3" % .",,e_ LJ�,,
12. Please describe the vegetation above the Aormipool lake level/ Normal Water Level and
50 feet landward to be impacted (number of trees, for instance): M&r(—
&,.,, /0 1651
Owner/Agent's 'gnature* [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

.0 .
Full Pond/
Normal Water Level
SI
Lake
(At Full Pond/ Normal Water Level)
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

9/19/2016
ONNE(-;GIS
I WEE t:c_'T •Nt:
-yW l - .
ConnectGIS Feature Report
Person
Printed September 19, 2016
See Below for Disclaimer
Parcels
Progress Areas (1)
Progress Areas (2)
0
Parcel Address Points
4111
Parcel Line dimensions
Lakes
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