20161022 Ver 1_401 Application_20161016

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
FOR DUKE ENERGY USE ONLY
Duke File No. 2 Q ' b,
Application Fee$ Security Deposit$ Check# Date Recv'd Initials ' 2
Date of Duke Energy Lake Services,applicant and/or contractor on-site inspections Date Initials
Date Final Protection/Avoidance Area Markings Field-Verified Initials
Approved to Start Work By*: Date
(Print) (Sign)
Date Completion Required Date of Any Approved Extension Initials
Date Passed Closeout Inspection* Initials
Any Stop Work Orders or SMG Violations*?(check one) OYes ONo (If Yes,explain in PART V)
Date Deposit Refunded Initials Date Permit Database Updated "
*Forward copy of approved application(all pages,plus any attachments that Duke Ener n$T}�ack to a lican D
with Approval Letter and highlight any changes.File copies of Approval and Close-out isN�aird�nj�S �lo
Orders with application.
- P RMI IN
PART L-APPLCANT ORIVIATION(Please Print) 8 FF R
-7
Name��'S/ r/I 4� �S /�/ Telephone 7C' !/ • ��
Lake Address� �V t a� �� ���� ��C Mailing Address
�J(�
(If dierent)
beN v e v-,
Contractor Company J� C
Contractor Contact Person ( d�/� r�" �t S Telephone
LAKE LOT INFORMATION
Lake6 L6rM!!6t_ County 1I ffee ✓ City � ��� StateV� Tax Map No.
Subdivision—S.4;/ e t) Lot/Section No. Lot Size Q. 71 Acres
Are there any Co-Applicants*?(check one) OYes ❑No (If Yes,include names,addresses,phone nos.,lot nos.,lot
sizes in PART V—ADDITIONAL INFORMATION) s Co-Applicants exist when the proposed work is being done under a
single application,will be performed by a single contractor as one continuous project and is done to benefit multiple owners/
lease holders of project-front properties within a single development The check for the application filing fee and security
deposit should be from the party shown as Applicant and not several checks from the Applicant and Co-Applicants-
Do not continue the application until an on-site inspection has been conducted between a Duke Energy Lake Services
Representative(DELSR)and the applicant and/or the excavation contractor. NOTE.Initializing this portion of the
application by a DELSR in no way constitutes approval or eminent approval the excavation or any other lake use
permitting activity-
Date of on-site inspection Initials(Duke Energy (applicant/contractor)
Duke Energy Page 1 of 14 rev 9/19/14
Excavation Program
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application 113 10.docx

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
PART H.-DESCRIPTION OF PROJECT
A. BASIC INFO
1. Type of excavation:(check one) ( New excavation O Maintenance excavation
2. Purpose of excavation:(check one) / Boat Access Channel O Water Intake Channel
t(�Wastewater Discharge Channel ❑Other(spec):
3. Lake user category:(check one) Private OResidential Marina ❑Commercial Marina
OPublic ❑Other(spec):
4. Max.Excavation Area Dimensions(ft): Length ,O Width 5 Depth
(Note:include additional area dimensions if necessary so response to 45 below equals max.area dimensions in 44)
5. Volume of Excavated Material(TOTAL for the project): 3 Cubic yards
6. Type of material removed(applicant determines by field sample if practical): IN(A S i#-
7. Excavation Site area: L-0 Acre(s) Disposal Site area: 6. o 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)XYes ONo
10. Do you claim title to the disposal area?(check one) Yes ONo
11. Do you claim title to the equipment staging area?(check one) �fes ONo
12. Are there any water-treatment facilities within 50 feet of the proposed excavation area?(check one) Dyes *o
(If Yes,spec):
13. How will the excavated material be trapped the a osion controlled?(e.g_see attached erosion control plan and
disposal area design): lfY�t�
14. Type(s)of excavation equipment to be used: '`9
15. Will waters or wetlands be crossed in transporting equipment to 0r from the site?(check one) OYes PU60
(Ifyes,explain) //`
16.Will return water re-enter the reservoir?(Check one) DYes lylo ON/A (If Yes,specify point(s)ofre-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? I es ON�
(If Yes,speck the existingpermit number. If No, include a scaled drawing of the proposed facility). Permit# 1 SAO
18. Total planned duration oftbp work(Include first equipment mobil' tion excavation through final mitigation measures
complete): START AW l _,'9LfJ16 FINISH y / I
(Month) (Year) (Month) (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 U.(Continued)
B. PROTECTION/AVOIDANCE AREA DESCRIPTION
Complete the following table including all land areas within and immediately adjoining the disturbed area:
Identification Method i*)
Protection/Avoidance Areas Aanrox.
(check all that apply) Acreage Field ID s!Work Area DwID Avoid(A)o*Mitigate(Ml
a. Marshland,swamp,ponds,beneficial
aquatic vegetation or other potential wetlands(circle all
that apply)
b. Buffer Zones(speck width&source of �pYK T t pN
requirement)
C. Environmental Areas as identified by Duke /'p
Energy �1/
d. Natural Areas as identified by Duke Energy /4-
e. Historic properties(spec fy) n
AII
E Rare or threatened species(specify) WA
Duke Energy Page 4 of 14 rev 9/19/14
Excavation Program
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DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
Identification Me h
Protection/Avoidance Areas Approx.
(check all that apply) Acreaee Fidd M Work Area Dwe.ID Avoid(A)or Mitigate(M)
**
¢. Buried gas,water,sewer,communications ,//�
or electric lines(circle) A
h. Impact Minimization Zones as identified by �/A
Duke Energy
i. Other areas requiring specific avoidance,
protection or mitigation(specify)
* For"Field ID"column,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 Smith)/yellow flagging). For"Work Area Dwg ID"column,show the symbol that is used on the drawings to identify the protectionlavoidance area.
** List and attach mitigation plans
Duke Energy Page 5 of 14 rev 9/19/14
Excavation Program
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DUKE ENERGY EXCAVATION PERNUT APPLICATION FORM
C. APPLICANT'S SIGNA URES
Comments: /�7Al f7 �/`�TrL� %j �' �p,¢r��✓ / / T `f
• �, 'S�� • Ej �S �
Applicant Name{print) nl/r Lot#
Applicant Signature* Date 6
Co-Applicant Name(print) Lot#
Co-Applicant Signature* Date
Co-Applicant Name(print) Lot#
Co-Applicant Signature* Date
Co-Applicant Name(print) Lot#
Co-Applicant Signature* Date
Co-Applicant Name(print) Loi#
Co-Applicant Signature* Date
Co-Applicant Name(print) Lot#
Co-Applicant Signature* Date
*Per my signature,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
• MET ALL REQUIREMENTS FOR A COMPLETE APPLICATION(see cover letter of application package)
INCLUDED A SINGLE CHECK TO DUKE ENERGY FOR THE APPLICATION FILING FEE AND SECURITY
DEPOSIT
INCLUDED ALL AGENCY PERMITS OR COMMENT LETTERS AND RESOLVED ALL ISSUES RAISED
• INCLUDED ALL REQUIRED DRAWINGS(INCLUDING PROPOSED FACIL T MS),PERMIT#FOR EXISTING
FACILITIES,•ITIES,SURVEYS AND PLANS
• INCLUDED COPIES OF DEEDS AND AUTHORIZATION LETTERS
Duke Energy Page 6 of 14 rev 9119114
Excavation Program
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application 113 10.docx

State of North Carolina
Department of Environment and Natural Resources
} 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
Four copies of the application (including attachments)and the application fee should be sent to:
Division of Water Resources
401& Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
1. Applicant Information 1`15A NCAC 02H .0502(a)]
1. Owner Information /J 114
-
Name: �,.$ ��_ /7�s SA t-A0
Mailing Address: ¢� 0 so<i2in/ d t ✓C u�'
Ze_n/✓e V-, 9C ;= _37
Telephone Number: 70 9106• Y"71'ax 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 AUTH
ORIZATION FORM. df must be attached if the Agent has signed this application form.
Name: i r'id4f_5
Company Affiliation: _3n Ne- f C69C st
Mailing Address: 39 (9m<ridicr►^
Telephone Number: d •5ll/ Fax Number: 70 d•5%'?
E-mail Address: C- �ff4 1.cW 9 �
Person to receive the Certification Approval: r k•o /5 rldyCS
II. Project Information [15A NCAC 02H .0502(a) & (b)l
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

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): ✓��"� �
Dir 'ons o se ope.se 2ctude road name,�sian numbbers, la d narks, eetc.: �I�de L. /<�C I"' I$
e�fJ J �1/a CirtrC,�' �t
Latitude(in decimal degrees)I f. l Longitude (decimal degrees) . �7 i�
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): �� 5 L
6. Property size (acres): 4,
K�
7. Lake/river/ocean adjacent to property:
8. Describe proposed work(include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): &7,,
9. Will work be conducted from land? [ From water? fV
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:
5® rX
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): MC
14Z
Own r/Agent's Signature* Printed Name Date
[15A NCAC 02H .0502(f)]
'Agent's signature is valid only if an authorization fetter from the owner is provided.
FORM:SSGP 10-2013 Page 2 of 3

Lake
(At Full Pond/Normal water Level) t
Full Pond/
Normal Water Level.
WE .
Shoreline
.� 6""C L
5
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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VICINITY MAP, CURVE TABLE, LINE TABLE. NOTES AND 4__ `\\`%' "90 SMrveyi NE D ER i199EriRs
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