20160946 Ver 1_401 Application_20161016

Q 2 0 1 60 9 4 6 state of North Carolina
Department of Environment and Natural Resources
v Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilisation
yo dF W44-62 as bJ2dS FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
1.
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Applicant Information [ 15h NC I+C 624. 05'6,1 ]ai
Owner Information
Name: K%IIlVt 774 C , , LgAfSo x/
Mailing Address: Y06 C&blf_2 CleiLS% G' l'�e&4E
001,AO /�0 CK , 7-C 7P -6G5-- 627/
Telephone Number: <S/Z X 33 x'/33 Fax Number: k22 a - 7,V2 - 26 a
E-mail Address:
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
h i-+� :%�w w w, s' a w, usn. c e., a.rr►+y, M t �/7e �) s�.Si�dc cs/royvlo+�ory/r+�� docs ff�,y*� i ¢s�s�+rlP[,ES
must be attached if the Agent has signed this application form.
Name: _ ?08 f'%9�Ti N / %t/� SJ,4fcv,�_ C'v/ %%9 n1 riu-
Company Affiliation:
Mailing Address: _� 0 _ l3D,C 3C?
%4,C -Ar KI 1 t✓ K ZY C', 017 3 C
Telephone Number: PLS- 2-Z6 26 V7 Fax Number: ?2-R-- 75_43 ✓zv ZZy
E-mail Address:
Person to receive the
Approval:
Project Information [i 5,-A AMA,' oxN, 0-5-m (4) °' 6o]
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: Nearest Town:
Subdivision name or site address (include phase/lot number):
/9064C AIA -1012 /S L-'¢N,D GD T rw /0
Directions to site - please include road names and numbers, landmarks, etc.:
j O- 01 CILSWI:2S 10-711 % a s 6! Vl LGA 7_2
SCtfooL r2d iu2�0 cfEFT - /2 ��� ��,'
10 09y2Ti9-ref/ls �D405 614-2ee -%&,-,< YOy /7 E.sLe uO
Latitude (in decimal degrees) J� Longitude (decimal degrees] ? , 1!369617
5. Describe the existing land use or condition of the site at the time of. this application
(residential, undeveloped, etc.): 00 -CV J-;C-OPf'r.0 ROAt, _ 5(7-r&-
6. Property size (acres): 1, 6 t
7. Lake/ river/ ocean adjacent to property: 1 �% GE.✓( Cd,
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
T
W k T9 (Z1 P PI+P 1W L
9. Will work be conducted from land? ❑ From water?C]
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:
b0 S C,
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 ll
square feet or acres: to oo S0, 1
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): So r-,% f�_
y-- F A -U 4; N (VZiZ S 0 D IJ4s_O 72� ZfL V kV 0 ii --L
o/
Owner/Agent's lgnature; [ 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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