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Home My WebLink About20170053 Ver 1_Shoreline Stabilization_20170110 State of North Carolina Department of Environment and Natural Resources [)' I Division of Water Resources Water Resources ISA NCAC 02H.0500—Water Quality Certification,Shoreline Stabilization Division a FORM: SSGP 10-2013 Shoreline Stabilization Application Form Four copies of the application(including attachments)and the application fee should be sent to: Division of Water Resources 401&Buffer Permitting Unit 5 3 1617 Mail Service ire 7 0 1 7 0 Raleigh, 219 f6 0 1. Applicant Information 11.5A ✓,y5A NCAC 02H .0502(a)] N1 �� Information 1. Owner information 0� � �, (d me: � . i-o^y e PeP X1.9 Mailing Address: --put 3S� et -r_�,,., t} A • . Telephone Number: t Y 7- f -5t 9 Fax Number: E-mail Addresskp —... ) � l4 c.0 2. Agent/Contact Person Information r' 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 ORIZATION FORM.pdf)must b,attached if the Agent has signed this application form. Name: _ c,"*.eye Company Affiliation: Ph:i'. t4)6,41�1 y .-. `, , .0At Mailing Address: t `t 13 tt -,-i, ri L "2:7 v Telephone Number 5,3„ 4-7— h r= Fax Number: TA E-mail Address: L . L°,7 r1. Person to receive the Certification Approval: cry o l'p. , 11. Project Information [15A NCAC 02H .0502(a) & (b)i 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 4 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: Fr•a-y1 k L h Nearest Town: B cz 1,7‘. Subdivision name or site address(include phase/lot number): La 7 jy 1;. AO Directions to site- please include road names and numbers, landmarks, etc.: 3=r0 914.01-,‘ \sAly )-..r r� �...-�?;�'t U., �-� ��1 m 2 P/ i17.0 P I'-'7 771 t L-a ft '7'" • r / .� 5. Describe the existing land use or condition of the site at the time of this application (residential, undeveloped, etc.): , • _ / 6. Property size (acres): iii(" ( cf .ic) 7. Lake/river/ocean adjacent to property: � k,., R=Jr. Q 1.-.° 8. Describe proposed work(include discussion as to how hardening of shoreline has been avoided, or why it is necessary): '> (fes ;�� , t�� r ;.t„l-v 41C) r- p,' ;211‘,-),:./ Lys-? 9. Will work be conducted from land? rg )( E5 From water? n 10. Total amount of disturbance(including all excavation, backfill, rip rap4e.lainin wetc.) below the normal pool lake level/Normal Water Level in square feet or acres: 3/2 S ' 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: 34i'+- 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): Y)0'14,3 iX T) j ►✓G1j/ �,�� !✓lam! f �' TkC°17 Owner/Agent's Signature' [15A NCAC 02H .0502(f)1 Date "Agent's signature is valid only if an authorization letter from the owner is provided. FORM:SSGP 10-2013 Page 2 of 3 Scan 24170102(2).png lritps:ftmail.google.comt_tscstmail-static! fjstk=gmail.main.en.Az... EXAMPLE AGENT AUTHORIZATION FORM Property Lege Descrioton �arceiID i L. Lot No. (it applicable, Plan No lif applicable) Street Address(if abbircablef�6 - �rfr)u:' I '4', Prppertv Owner. fawnrr Name(nrinti• _ ' r/ IL!! • / Property Owner's Address(if different than the above); /1/4! Owner Signature: .._ *• :�J 4 �df The above registered property owners of the above property,do hereby authorize L---Stet/4 $iL of � .ts �tadtit *+a Agent Name Agent Company Name(if opal/Cable) to act on my behalf and take all actions necessary for the&pprrcation,processing,issuance and acceptance of this permit,certification or authorization including all standard and special conditions attached. hereby certify that the above information submitted on this form and application is true and accurate to the best nt my knowledge. r Authonted Agent Name./Company ...siltat t 6? ./ (17 Ik:5 :"P if z,)f Authorized Agent Signature: � = �•-!/ -- Date' 4 of 1 162/201712:52 PM Lake fM FuH Pond/ Nonnat WaWr Ie%" at 5�a l� 1=csN mond/NorfflWar 00 Shoregne36+40 8 u(.k�•tR 34� QK�Kh LwdNo sf fp-r Sew GMsi bQ y � n X XyQ_ri �z Vk r Please approximately sketch the following information on this plan (provide ddmensibns for eaeb item, such as 10 ft x 100 ft)*: 1_ All proposed vegetation clearing 2. Location of rip rap or f9l 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 fond,/ Normal Water Level ,exon 6. Location of construction access corridors FORM: SSGP 10-2013 Page 3 of 3 mm .■■Emmmm■■..MEN ■■■■■■■■■■■ ■■■N■■■.■ ■■■i1m■mb m■■■■■■■.■■■■■.. ■ MEN ■■■.■■■ ■. ■■■.■N\■■■■■■■■■■H■■■. ■■ ■■■■■■NEE ■N■N ■EIS■■N ' :�■■■.■■■■■■■E■■..■■H■EN■E■ ■■■E ■■IMIS RENNEE■E■EH■■ ■■■EN.■■E■E ■■■E ■.U■H■EN-C■E■E■E■E■■H■NH.E■■ ■■■■■■�;.■N■■.■ ■.■■N■EMEN ■E■■E■E■E ■■■.■.�I.N...■.►!■ E..■■.■N■■..■N■E ■.■i �� f l■N�■■■■...■►`■■■■�.■■.■■.■.ME■ ■E■■■■■■■iiiS■N■....\`\■!!i'■■■■Emaz mad ■■■■ipEoEmiii■N E■■■►N .�'�I�i.■�!A!C'i■i�l.H. ■■.■ ■�.■E�':Ill'/■oi'�■/_!�.�i%■L � �■■iii■■■■. ..HH■It■��i�NEH■.■. 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