20161164 Ver 1_Shoreline Stabilization_20161128

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Q OJ25 NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
DIVISIad 6F W4MQ FORM: SSCP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments[ and the application fee should be
to:
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Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Applicant information [ 15'A 46I+C024. 05'67. )0.i
Owner Information
Name: PO"'Z> q_ Ev�Y
Mailing Address: 1{930 s . S��c�=or'b ayF
5;yw �70 /'�
Telephone Number: X07- 92 0-2 6 2 � jax Number:
E -malt Address: �/ ) rcV/I y / / Noo,Ce:rJ e,+k o;-, c- 7 ct o% GV/X­'
Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
hf'f'p :l/ww•.�. s ctiw. ✓sacs, w-.,+sy. �+I ��Aop� sfS`9�� �s/rer�v/o�ory�i�*�dxs,�r++���s�-s/i�lP[F_S
�G /�T i4vr�vorz�z•¢r/o.J Fo2� '
must be attached If the) gent s signed this application form.
Name: .��rs' /� /lt✓-S�/}z�J�--(,�- (CC
Company Affiliation: Y0 / C°y�S / Z �= "X
Mailing Address: - i7 - J
Telephone Number: fax Number: No& -7 y 3 -6`7-6
E-mail Address:// C"6 c,c S6 C C -'-.O /' C: G�-t
Person to receive the Certification Approval: /,0 %f-1 -1&0 y
Project Information [is'A NeAc Oz#, 05-0-L (0) V �m
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.
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

A
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: -�'�!�Z"%! S Zi% Nearest Town: �c' ��L ey
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.:
. W Y to 6eg€ < I2
TO 0 6�_ 517" E G002 v' .lutea -E 2V70
Latitude (in decimaidegrees) L. I —i-30 t- Longitude (decimat degrees) 6-3, 16 7 94
5. Describe the existing land use or condition of the site -at the time of this application
(residential, undeveloped, etc.): _ /�_S t]bP-770-r5- �) O eie 607-
6.
'Dr6. Property size (acres):Z r -'
7. Lake/ river/ ocean adjacent to property:�/yl'%cG
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 4-M 5? -b J
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:
p0 --cV
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: l
O C Q rte_ i
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): -3 0
Owner/Agent's Signatui
'Agent's signature is valid
FORM: SSGP 10-2013
l-
Date
if an authorization letter from the owner is provided.
Page 2 of 3

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