20160950 Ver 1_401 Application_20161016

DUKE ENERGY EXCAVATION PERNUT APPLICATION FORM
°�sos5p
FOR DUKE ENERGY USE ONLY
Duke File No.
Application Fee $ Security Deposit $ Ch /�Iecv'd
Date of Duke Energy Lake Services, applicant and/or contractor on inspections Datet4JS Ki
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
(Sign)
Initials{�
Initials delil
Initials
Date
Initials
Any Stop Work Orders or SMG Violations*? (check one) ❑Yes ❑No (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 I. - APPLICANT INFORMATION (Please Print)
p e" MAA(—
NameRe�! gS tAAq I /� ��-��A S p Ass � . - Telephone 70 4,4� 3
Lake Address ,Qq / 1461©d Mailing Address 11609 Be1iI �Sk]A Pot Al f e Ar
(If different)
Contractor Company
A-rarPl C-rrea SrApe5 5tv-YiGe5, L> -G
Contractor Contact Person C U I.J`r' A'1e S Telephone (76 q)
LAKELOT INFORMATION / ( /s
Lake 1 T ar�-�N County t' ICKIetd & City a rde,(�'XS State dC Tax Map No.
Subdivision / e- pety 1 11l S J4_ Lot/ Section No. Wfteny Aae-55 Lot Size •2.12- Acres
Are there any Co -Applicants*? (check one) ❑Yes ❑No (If Yes, include names, addresses, phone nos., lot os., lot
sizes in PART V - ADDITIONAL INFORMATION) * Co -Applicants exist when the proposed work is being done
single application, will be performed by a single contractor as one continuous project and is done to benefit multiple
lease holders of project -front properties within a single development. The check for the application filing fee and se
deposit should be from the party shown as Applicant and not several checks from the Applicant and Co -Applicants.
OcT
Do not continue the application until an on-site inspection has been conducted between a Duke Energy La11
Representative (DELSR) and the applicant and/or the excavation contractor. NOTE. Initializing this portio
4
application by a DELSR in no way constitutes approval or eminent approval of the excavation or any other lake use
perrnh ing activity.
Date of on-site inspection QQ FS Ju Initials (Duke Energy) dedi1_ (applicant/contractor)
Duke Energy Page l of 14 rev 9/19/14
Excavation Program
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application 113 10.docx
3 ?016

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
PART H. - DESCRIPTION OF PROJECT
A. BASIC INFO
1. Type of excavation: (check one) YNew excavation 13 Maintenance excavation
2. Purpose of excavation: (check one)&mWastewater
oat Access Channel O Water intake Channel
Discharge Channel O Other
3. Lake user category: (check one) OPrivate bkResidential Marina OCommercial Marina
OPublic 14+❑1 (specify): ---_— -
0 3
4. Max. Excavation Area Dimensions (ft): Length a Width It Depth _
(Note: include additional area dimensions tfnecessary so response to #S be equals max area dims tons in #4)
5. Volume of Excavated Material (TOTAL for the project): --R 6' 3— . Cubic yards
6. Type of material removed (applicant determines by field sample if practical y 5 iF
7. Excavation Site srce:_-jQj— Acre (s) Disposal Site area: D • / 29 Acre (s)
8. Total Disturbed Area (including equipment staging area):__ _ Acre (s)
9. Does the project meet the requirements of the applicable General Permit? (check one) Kyes ONo
10. Do you claim title to the disposal area? (check one) XYes C3No
11. Do you claim title to the equipment staging area? (check one) KYes ONo
12. Are there airy water -treatment facilities within 50 fat of the proposed excavation area? (check one) Dyes *o
(#'Yes, specify):
13. How will the excavated material be entrapped and the erosion con�Qlled7 e.. see attached erosion control plan and
disposal area design): MAref Y if I w; 11 be _ �'►A, Ge -I hu % A'r4C
14. Type(s) of excavation equipment to be used:
15. Will waters or wetlands be crossed in transporting equipment to or from the site? (check one) OYes XNo
(Ifyes, explain) -
I & Will return water re-enter the reservoir? (Check one) Oyes 1KNo ON/A (If Yes, specify point(s) of re-entry and
show on Excavation Area Drawing)
17. Is there an existing facility (e.g. pier) that access is being maintained to by conducting the excavation? es ONo
(If Yes, specify the existing permit number. IfNo, include a scaled drawing of the proposed facility). Permit#
18. Total planned duration of tht work (Include first equipment mobil' ion excavation through final mitigation measures
complete): START_41&V l _4p((p FINISH / -APW
( Mewh) (Year) (dMonth) (year)
Duke Energy Page 2 of 14 rev 9/19/14
Excavation Program
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application 113 10.docx

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
PART IL (Continued)
B. PROTECTION / AVOIDANCE AREA DESCRIPTION
Complete the following table including all land area within and immediately adjoining the disturbed area:
ProtIS#gn/AvoidaaeeArea
(check all that apply)
Approx.
ACreA2G
Ideoti cation M (hod "
Avoid (A) or Mitianbe (Ml
Field ID
Work Area DwQ. ID
a. Marshland, swamp, ponds, beneficial
aquatic vegetation or other potential wetlands (circle all
that apply)
414
b. Buffer Zones (specify width & source of
requirement)
wo r, 2 tin
V�e-
-c.Environmental Areas as identified by Duke
Energy
t „
d. Natural Areas as identified by Duke Energy
e. Historic properties (specify)
t. Rare or threatened species (specify)
/V/
t4
i
Duke Energy Page 4 of 14 rev 9119/14
Excavation Program
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DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
Pr t n/Moi Luce Area
(check all that apply)
AQp,rox.
Aerwee
Identitreatiaa Metbod (6)
Avoid (A) or Mitisate (Ml
Fvid ID
Work Area Dws. ID
z Buried gas, water, sewer, communications
or electric lines (circle)
A
K
L Impact Minimization Zones as identified by
Duke Energy
'jlA-
i. Other arm requiring specific avoidance,
Protection or mitigation (aped)
. I A-
• For "Field M" oolumn, 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 Smithy yellow flagging). For "Work Area Dwg ID" column, show the symbol that is used on the drawings to identity the protection(avoidgmce area.
** List and attach mitigation plans
Duke Energy Page 5 of 14 rev 9/19A4
Excavation Program
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DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
C.APPLICANT'S SIGNA
Commmts: CA r 5 �o W1 iffJ /9/4
Apphmnt Name (prem)
Applicant Signature*
Co4pplicaut Name (print) 0"tj
s
co A"plicant Sigaatare*
Co -Applicant Name
Co-Applimat Sigaat
Co -Applicant Name (prvrt)
Co -Applicant Signature*
Co-Applieant Name (print)
Co -Applicant Signature*
Co -Apple mt Name (prim)
Co-Applienat SigsataW
29
Lot #
Date ji �
Lot #
Date I 411L
Lot #
Date
Lot #
Date
Lot #
Date
Lot #
Date
*Per my signor, the information provided in this application is correct to the best of my knowledge.
BEFORE YOU MAIL THE APPLICATION TO DUKE ENERGY LAKE SERVICES ENSURE YOU HAVE:
CHECKED THE INFO THOROUGHLY
• MEP ALL REQUIREMENTS FOR A COMPLETE APPIICATTON (see cower letter of application package)
DKLUDED A SINGLE CHECK TO DUKE ENERGY FOR T7 -1E APPLICATION FILING' FEE AND SECURITY
DEPOSIT
INCLUDED ALL AGENCY PERIiM OR COA04ENNT I E" TIERS AND RESOLVED ALL ISSUES RAISED
• INCLUDED ALL REQUIRED DRAWINGS (INCLUDING PROPOSED FACILITIES), PERMIT # FOR EXISTING
FACIIITTES, SURVEYS AND PLANS
• INCLUDED COPIES OF DEEDS AND AUTHORIZATION I EI'IERS
Duke EnMU Page 6 of 14 my 9119114
Excavation Program
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application 113 10.docx

State of North Carolina
nw
Department of Environment and Natural Resources
Division of Water Resources
BMW 1q V R
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
Raleigh, NC 27699-1617
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information O�1S�Name: IAf_,xc SOCD Z
r,✓44<_
Mailing Address: Porgy✓ C_ P'-•
�'c►�Aie�'u e, C' 9_'03/
Telephone Number. -701U40_ D_Xe® 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/regulatory/regdocs/Permits/SAMPLE AGENT AUTHO
RIZATION FOR . df) must be attached if the Agent has signed this application form.
Name: ;/J 8v-&qt5
i
Company Affiliation: if t'A�rYce-,v SCg7-)t 5 ✓Vice S
Mailing Address: Q Df}K r �4 cFm w
/i'I�ovcsv� Iii. C P1IIS
Telephone Number: 0.5111 Fax NuT ber: 70 �6d •
E-mail Address: CIO-SlflaMO5 IiWdsfr *,*" • Nit
Person to receive the Certification Approval: !fA&741e-5
eS
II. Project Information 115A 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-44ak �� Nearest Town: 1 ./� {Ale/,�t 5
Subdivision name or site address (include phase/lot number): �;q �tNin/Su.%
Dir ctions to site please inclu a road am and umbe s, landm ks, etc.:AO
Latitude (in decimal degrees) 3 �'. Cl 2 Jf Longitude (dedmal degrees)] /� .1 �!o 2-
5.
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): '/ �+� ( ss 6 c400.—
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:
c Ni r,
8. Describe proposed work (include discussion as to how ardening o shoreline has been
%
avoided, or why it is necessary): cl_
1 N Y - 1- C tS -5
9. Will work be conducted from land? Nk From water? ILi,
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:
�±4- C*o'X 5' 4a'x4�'X s" -40 �x 5 x 5 r
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): 60' L_tAtlQ.d
Owner/Agent's Signature* Printed Name Date
(15A NCAC 02H .0502(f))
'Agent's signature is valid only if on authorization letter from the owner is provided.
FORM: SSCP 10-2013 Page 2 of 3

No
Lake
(At Full Pond/ Normal Water Level)
/L�.a. /
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.
S. 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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*THIS MAP IS NOT A CERTIFIED SQRVEY
AND NO RELLANCE MAY BE PLACED 114 ITS
EXHIBIT A
TO
SUPPLEMENTARY DECLARATION
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