20161117 Ver 1_Shoreline Stabilization_20161115

State of North Carolina
DWR Department of Environment and Natural Resources
Division of Water Resources
Division of Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the applicati
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center 2 0 j
Raleigh, NC 27699-1617
I. Applicant Information [15A NCAC 02H .0502(a)1
1. Owner Information
Name: �q/1
Iviailing Address: 065�j r
tf - &&d. ac— .2 7?0
Telephone Number: 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.mi!/Portais/59/docs/regulatory%regdocs%Permits/SAMPLE AGENT All T H
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: KOWT ru L(6112h
Company Affiliation: I e 516�� C�0/1i✓ctCJ%(s
Mailing Address: 1057.1 Waf'OW day 4J
Norf,oad t !JG 121r/2f
Telephone Number: 7.Dy Q�16 Fax Number:
E-mail Address: T'hw ('d y" W(Ad OYM M, Altf
Person to receive the Certification Approval: R(Qt(��G�er
11. Project Information [15A 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,
=ORM. S5GP 100-2013 Page i 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: /� A- r-4 CI Nearest Town: �
Subdivision name or site ad ess (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.: /_�173
/1PA-rv&r-
S-� z 6S1
Latitude r.°n tlecimerl.aegreesJ � � Ongltude (decimpof degrees] d D1 10,O 76 a
i�cc
5. Describe the existing land use or cdition of the site at the time of this application
(residential, undeveloped, etc.): 2�" dcA� a/
6. Property size (acres): 1/2- a IC p� F�- _S
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening A shoreline has been
avoided, or why it is necessary): S 1 oer, I S E& 1� i 1 r :;� e—+1� k r
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:
i ,;i. O r+ Yt 3 rnNyoc-,-k B& i c i �i a I i I aid
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
square feet or acres: [ '�, 0 F+- X 3 T+ -',vA ►nr—c A of t Fgd /,C)
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): S L- U L i a,
y S - A c=
& /"!g 0116
Owner/Agent's Signature' [15A N C 02H .0502(f)] Date
'Agent's signature is valid only if on authorization letter from the owner is provided.
FORM: SSGP 10 2013 Page Z of 3

Nor
lake
(At Full Pond/ Normal Water Tavel)
2,0 X 3 Pf 13L -loo
El
kI'PRq-P
Please approximately sketch the following information on this plan (provide dimensions far 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

r
FA
SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO.`�� PLAN NO. PARCEL ID:
STREET ADDRESS: 2 r7 C 411 V Col
wJ j,
Please print:
Property Owner:
Property Owner:
Crov
The undersigned, registered property owners of the above noted property, do hereby authorize
'
(Contractor / Agent) �f (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
rr erty Owners Address (if differ nt than property above):
T
895-661-gS.51
M hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Cow-
'�Jju oriSign rre
Date: I
Authorized Signature
Date:

North Carolina Department of Natural and Cultural Resources
State Historic Preservation Office
Ramona M. Bartos, Administrator
Governor Pat McCrory
Secretary Susan Kluttz
October 20, 2016
Maryellen Crane
8005 Twin Harbor Drive
Mount Gilead, NC 27306
Office of Archives and History
Deputy Secretary Kevin Cherry
Re: Soil Disturbance, 217 Crain Court, Lot 3, Mount Gilead, Lake Tillery, Montgomery County,
ER 16-1755
Dear Ms. Crane:
Thank you for your application concerning the above project.
We have conducted a review of the project and are aware of no historic resources which would be affected
by the project. Therefore, we have no comment on the project as proposed.
The above comments are made pursuant to Section 106 of the National Historic Preservation Act and the
Advisory Council on Historic Preservation's Regulations for Compliance with Section 106 codified at 36
CFR Part 800.
Thank you for your cooperation and consideration. If you have questions concerning the above comment,
contact Renee Gledhill -Earley, environmental review coordinator, at 919-807-6579 or
environmental.review(d�ncdcr. og_v. In all future communication concerning this project, please cite the
above referenced tracking number.
Sincerely,
Ramona M. Bartos
Location: 109 East Jones Street, Raleigh NC 27601 Mailing Address: 4617 Mail Service Center, Raleigh NC 27699-4617 Telephone/Fax: [phone]-6599

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