20161166 Ver 1_Shoreline Stabilization_20161128

State of North Carolina
Department of Environmentes
Divisi es
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 application fee should be
sent to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center 2 0 1 6 1 1 6 6
Raleigh, NC 27699-1617
l . Applicant Information 115A NCAC 02H .0502(a)] D a M
1. Owner Information V
Name: Chevy I MOSS Hol hof, ejd NOV 2 8 201
Mailing Address: 46-15 ZSt?nkaui^ Po4At DEQ- ATER RE oUR
{�n n p pv i S c' 2 08 1 401 '-BUFFER PERMIT
Telephone Number: 004)363-56`5�3(c-) Fax Number: (704)q32- 5959
(704) Cfi32-914 , W
E-mail Address: r � r� l (� i �� d Care (; nGc. , rr-, corn
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.miI/Portals/59/docs/regulatory/reg
docs/Permits/SAMPLE AGENT AUTHORIZATION FOR
M.pdf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:

E-mail Address:
Person to receive the Certification Approval:
11. Project Information [15ANCAC 02H .0502(.AJ&Jb)]
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 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: Mooresv" 11 e') "G 2 11'7
Subdivision name or site address (include phase/lot number):
la$ Skorel' ne_ LcoP
woor-5'11 1( e IJ C 281 l r7
Directions to site - please include road names and numbers, landmarks, etc.:
&c, Glo�cn 13riLwicy �5ekvof leo, 6-f,12- lVi'llidmSon tZj,
'T
/�Ut-n Leif' cn +o S -f -O S 124. Near �( Dorn, A499onolcfrs� eA5s - (fi,15)
leo a6oLi.-r (eS 405kore1,`ne Loop (TZwn 12+f)
Latitude (in decimal degrees) -
Longitude (decimal
degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):
Res,tJ4 n4i a
6. Property size (acres):-Arr,,o y, '5 acre S
7. Lake/ river/ ocean adjacent to property:
Lake
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
%OS' o-' bloc%. for Stiorel.��
'O -F e rosy D $I
9. Will work be conducted from land? Yes
S fG.bi zu-�•'or!�r
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:
�o� Surma, Su//m Ld„ W,5;cu?/'h5 AV,`!C be. d©i`n

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: ` //
/Vel 5"r2, �Jiry► ef!5�re, dQ%r7I Wt, "o
J
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):
SAawSet n off" be- roq
One, pine- -�ree, Mal 'fiVolVe-d
Owner/Agent's 19ignature* `� Printed c h e4-
Name Date
[15A NCAC 02H .0502(f)-1
Agent's signature is valid only if an authorization letter from the
owner is provided.

. �] 'ei {,'� � SSGP :0>)1? d:agrani.ppGx - M�crrsaft FtrmrVant
a/
Home Imert Design tunmatwns StiCe Show Review View tastifthe
._.l _j Layout• : _, _ _ Il , .. ,
I u
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Paste New
Slide - ,j Delete
Uipboartl Font Paragraph
La ke
(At Full Pond/ Normal Water Level)
L }' Attanye
Dravnng
Full Pond/
r—►
Normal Water Level
Shoreline
—13/0e1<- waul` IC, Rn ,,ez,
ke. atc fye-v W/t"0° 5
bon 54ru cli`bra ACC12 5s
ka�et- -7?--�
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 1 of 3

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See Below for Disclaimer
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ne maps prepared for this website are generated from recorded deeds. plats. and other public records. Users of these maps are hereby notified that the information
4
herein should be verified. Iredell County assumes no legal responsibilities for any of the information contained on this site. Users are advised that the use of
ny of this information is at their own risk All maps on this site were prepared using a 1 OOO.W - Grid based upon the North Carolina state Plane Coordinate system
cim the
the 1983 North American Daturn. The delinquent real property tax overlay is updated monthly. The information presented is not intended to be used or relied upon
Addresses
Residertlal Use
Streets
RBMO
US Hwy
Slate Hwy
Main Road
Local Road
Residential
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�
ne maps prepared for this website are generated from recorded deeds. plats. and other public records. Users of these maps are hereby notified that the information
4
herein should be verified. Iredell County assumes no legal responsibilities for any of the information contained on this site. Users are advised that the use of
ny of this information is at their own risk All maps on this site were prepared using a 1 OOO.W - Grid based upon the North Carolina state Plane Coordinate system
cim the
the 1983 North American Daturn. The delinquent real property tax overlay is updated monthly. The information presented is not intended to be used or relied upon

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