20161206 Ver 1_Shoreline Stabilization_20161208

State of North Carolina
Department of Environment and Natural Resources
DWR 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 2 0 1 6 1 2 0 6[ 0 Vv
Raleigh, NC 27699-1617 nF D
C 0 g 2016
Applicant Information [15A NCAC 02H .0502(a)] 401 &-a# 1c, R S uR
1. Owner Infnrmatinn
Name:
Mailing
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.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATI FORM. df) must be attached if the Agent has signed this application form.
Name: 7Z'�� �S�,CN
Company Affiliation:
Mailing Address:
Telephone Number:'O`_'� 3"�O� Fax Number:
E-mail Address: 7c
Person to receive the Certification Approval: Z7���ay�
Project Information [15A NCAC 02H .0502(a) & (b)]
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 3

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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. Locationofthe property (where work is to be conducted)
County: \Xpl ---\QAZ�� Nearest Town: ���`�r\�e--
Subdivision name or site address (i ude phase/lot number): \\��,\
Directions to site - please include road names and numbers, landmarks, etc.:5��'—���
Latitude (in decimal degrees)! J , \�Longitude (decimal degrees)'
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): f e- 8 7 c)e.t_T''g, k
6. Property size (acres): %--% �.
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):�'td9 h?�4-�`t (iL •, �,�v,�
TM2,L- s� • w , - 4-c ,S774,a '_ ,%% W_ A -i /00f "k), 'i a, %ia 77"4,cA5-
9. Will work be conducted from land? El 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:
►nt-al Vvl�w,,.�.. d� d rt�s� �-t-e,,n�(: ids- c.v !�
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: ZrOO S °! • 'F'
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): /VGTr•��c•S
.01
Owne gent's Signature*
Printed Name
[15A NCAC 02H .0502(f)]
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013
Date
Page 2 of 3

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. I;E -'-'
PLAN NO. `-"/���PARCEL ID: ��3_�\& —\' o
STREET ADDRESS \\C"*\�\`
Please print:
Property Owner: `1
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
(Contractor /Agent)
(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.
Property Owner's Address (if different than property above):
Telephone: n��`
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
.Wtfiorized si ure Authorized Signature
Date:-\ — vp
Date:

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Full Pond/
Norrr-1 %A/ -- I --
La ke
(At Full Pond/ Normal Water Level)
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft)*:
I. 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.
S. 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

Information for Division of Water Quality
Regarding proposed Dredge project
John Raymond
11901 Pinnacle Point Lane
Charlotte, NC 28216
Scope of work:
Dredge with a hydraulic bucket dredge from shore, within
the 100 ft buffer. Spoil loaded onto trucks and hauled off-
site.
Duke Energy has pre -approved the work via meeting and
we are in the process of going to the various other
agencies to gain approval.

We will move the machine to three locations along
the path. The dump truck will be adjacent to the
bucket dredge, accepting the material. The dump
truck will travel through the yard and exit the
driveway.
1. 10' x 110ft. Travel path to work site in the 100ft. Buffer
2. Three 10' x 20' staging dredge locations
3. 10' x 80' additional travel path to move the dredge and
trucks to the out reaches of the dredge site (moving
towards the mouth of the cove)

Shows overview of path, similar to the previous
page, but overlaid onto an Ariel.

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