20160821 Ver 2_Shoreline Stabilization_20161116

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
FOR DUKE ENERGY USE ONLY
Duke File No.
Application Fee $ Security Deposit $ Check # Date Recv'd Initials
Date of Duke Energy Lake Services, applicant and/or contractor on-site inspections Date l l t v 1 Li Initials J ZY-111
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
Initials
Date
(Sign)
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
_7Uly
NUV
s zoos
* 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 aaDlication.
PART L - APPLICANT INFORMATION (Please Print)
Name L e l_ Ayrtf�GUK 5 )
Lake Address�t`! �( I/C 4 e.,
:::�414m4-� ./vie
Telephone Z$t) 9 %3. 7000
Mailing Address PC/ A-JDKL _'1
(If different) 5-7—Ale-5
'e5 !ll ll P A C i -d 6 0 7
Contractor Company C_./JC Q ��1�1C �� J © �Y l 'i z/ ►T `^
Contractor Contact Person'�t �({ 5 Telephone
/it
LAKE LOT INFORMATION
Lak drn ' County C �� ff City / State A/C Tax Map No.
i
Subdivisionl(,)%)VA) 6Ve5 oN /t ot-rtScAI Lot / Section No. 10 Lot Size Acres
Are there any Co -Applicants*? (check one) ❑Yes ❑No (If Yes, include names, addresses, phone nos., lot nos., lot
sizes in PART V — ADDITIONAL INFORMATION) * 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 of the excavation or any other lake use
permitting activity.
Date of on-site inspection
11 Oulu
Initials (Duke Energy) cy—) n (applicant/contractor)
Duke Energy Page I of 14 rev 9/19/14
Excavation Program
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application 113 10.docx
171?irs-

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
PART H. - DESCRIPTION OF PROJECT
A. BASIC INFO
1. Type of excavation: (check one) kew excavation ❑ Maintenance excavation
2. Purpose of excavation: (check one) YBoat Access Channel ❑ Water Intake Channel
Wastewater Discharge Channel ❑ Other (specify):
3. Lake user category: (check one) *nvate ❑Residential Marina ❑Commercial Marina
( Public ❑Other (specify):
4. Max. Excavation Area Dimensions (ft): Length 0 Width +0 Depth 5
(Note: include additional area dimensions if necessary so response to #S below equals max. area dimensions in #4)
5. Volume of Excavated Material (TOTAL for the project): 320 Cubic yards
6. Type of material removed (applicant determines by field sample if practical):
7. Excavation Site area: 49. 6 5 Acre (s)
Disposal Site area: 0. 0 Acre (s)
8. Total Disturbed Area (including equipment staging area): Q, I Q Acre (s)
9. Does the project meet the requirements of the applicable General Permit? (check one) res ❑No
10. Do you claim title to the disposal area? (check one) dYes ❑No
11. Do you claim title to the equipment staging area? (check one) KYYes ❑No
12. Are there any water -treatment facilities within 50 feet of the proposed excavation area? (check one)
(If Yes, specify):
13. How will the
disposal area des
❑Yes *o
be entrapped and the erosion controlled? (e.g. see attached erosion control plan and
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) ❑Yes #40
(Ifyes, explain)
16. Will return water re-enter the reservoir? (Check one)
show on Excavation Area Drawing)
❑Yes �qo ❑N/A (If Yes, specify point(s) of re-entry and
17. is there an existing facility (e.g. pier) that access is being maintained to by conducting the excavation? ❑Yes ❑No
(If Yes, specify the existing permit number. If No, include a scaled drawing of the proposed facility). Permit # e. i 5 AP ro%r C d`
18. Total planned duration of the work (Include first equipment mobili* tin excavation through final mitigation measures
complete): STARTl �I�G FINISH / �6 6
nth) (Year) onth) (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 II. (Continued)
B. PROTECTION / AVOIDANCE AREA DESCRIPTION
Complete the following table including all land areas within and immediately adjoining the disturbed area:
Protection/Avoidance Areas
(check all that apply)
Approx.
Identification Method
Avoid (A) or Mitizate (M)
**
Field ID
Work Area Dwe. ID
Acreage
a. Marshland, swamp, ponds, beneficial
aquatic vegetation or other potential wetlands (circle all
that apply)
`
NIA
b. Buffer Zones (speck width & source of
requirement)
'j % K �G he- Jule -
&47 C-
c. Environmental Areas as identified by Duke
Energy
�r
d. Natural Areas as identified by Duke Energy
t 1(
e. Historic properties (specify)
E Rare or threatened species (spec)
,
J Pr
Duke Energy Page 4 of 14 rev 9/19/14
Excavation Program
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DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
Protection/Avoidance Areas
(check all that apply)
Approx.
Identification Method (*)
Avoid (Al or Mitieate (M)
Field ID
Work Area Dwe. ID
Acreage
**
e. Buried gas, water, sewer, communications
or electric lines (circle)
�( I
l A
h. Impact Minimization Zones as identified by
Duke Energy
t
N (A
i. Other areas requiring specific avoidance,
protection or mitigation (specify)
, j 1 p
* 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 protection/avoidance 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 PERMIT APPLICATION FORM
C. APPLICANT'S SIGNATURES
Comments:
649Adf 4-0
Applicant Name (print)
Applicant Signature"
Co -Applicant Name (print)
Co -Applicant Signature*
Co -Applicant Name (print)
Co -Applicant Signature*
Co -Applicant Name (print)
Co -Applicant Signature*
i I r logy'
Lot #
/o
Date 3-19-2614
Lot #
Date
Lot #
Date
Lot #
Date
Co -Applicant Name (print) Lot #
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 lever of applicaflon 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 FACILITIES), PERMIT # FOR EXISTING
FACILITIES, SURVEYS AND PLANS
• INCLUDED COPIES OF DEEDS AND AUTHORIZATION LETTERS
Duke Energy Page 6 of 14 rev 9/19/14
Excavation Program
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application 113 10.docx

State of North Carolina
Department of Environment and Natural Resources
D R 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
Raleigh, NC 27699-1617
1
Applicant Information [15A NCAC 02H .0502(a)]
Owner I `
Name:
Mailing
Telephone Number: 7cV V5. 70iM Fax Number:
E-mail Address: !A m 4-5 /4 C's r"-A"if2 • C[' YY)
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 FORM.pdf) must be attarhed if the Agent has signed this application form.
Name: f i,n / f - "-..q C'3 — --
Company Affiliati?on: C 1 v ec " 4 e -
Mailing Address: 9 041k V_ ick e- -0 vi 4 '
aoV__s\,; t Ile 11. 4e 9 YAL
Telephone Number: -7�• 6 e • S// / Fax Number
E-mail Address: C -5,0 4 -GS ILI S 14i" , hl t -
Person to receive the Certification Approval: C%c o rr lrs
II. Project Information f15A NCAC 02H .0502(a) & (b)1
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) ff
County: Z -r tICU Nearest Town: Tb(ctyh4i1
Subdivision name or site address (in lude phase/lot number):—T;,3 k N IJ COVt -
oA) J1 PrV-I-W J /87 lD
Ditions to ite -please include r ad namesand numbers, landmarks, etc.: SG ti Al., L.:!-cA)
''q-rA-4A PzrLl AJ 4 w u ;.J /_.sA/-AVae- O'U
1_�4AI // o G
Latitude (in decimal degrees) �%5 0 7� Longitude (declmwdegrees)O9/5S-A�59
S. Describe the existing land use or condition of tir sitf at the time of this application
(residential, undeveloped, etc.): ti ;A(XP�
476. Property size (acres): 4' 14t-
7.
. Lake/ river/ ocean adjacent to property: Lie
A)
8. Describe proposed work (include discussion as to how hrdern g of shoreline has been
avoided, or why it is necessary): Y G t S S
9. Will work be conducted from land? ❑ From water? 9(
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake leivel/ Normal Water Level in square feet or acres:
LSD X 40 X. S
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
feet landward to be impacted (number of trees, for instance): Awoam t/,5ev_
ICY-
Owne ent'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: SSGP 10-2013 Page 2 of 3

Ft
Normz
SI
Lake
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ftx 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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