20170174 Ver 1_Shoreline Stabilization_20170209

'I 7 0 1 7 4 State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
DWR 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
Raleigh, NC 27699-1617
I/P�wlprlicant Information [ 15A NCAC 02H .0502i�.
2. cyaw Information
77
Name: nM
Mailing Address: �� v ✓/�'Jo
L5 U FFEa 0 9 2011 fl�
Telephone Number: f7 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:
Lp `;wvVv;u sawv.u;u::_. .-,.v.mil/Portals159/-docs/reguiatory%regdocs/Permits%Sia[W F AGENT AUTH
"'70N FopM.ec=) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Person to receive the Certification Approval:
Fax Number:
11. 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

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:
0
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.:
6.
7.
8.
9.
10.
Latitude (in decimal degrees) LOriglUde (decimal degrees)
Describe the existing land use or conditi of thZit.t a time of this application
(residential, undeveloped, et)
Property size (acres):
Lake/ river/ ocean adjacent to property:
Describe proposed work (included iscussio as to how hardening o sh reline has been
i . ,
avoided. or Whv it is nec�afy,):
Will work be conducted from land? From water? ❑
Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake level/ Normal Water Level Level in square feet or acres:
1J 1-1 v �,., "I = _.I GZ
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water Lev d 50 feet land -ward in
square feet or acres:
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to be impacted (numb of trees, for " an ):
Owner/Agent's Signature
Printed Name Date
Agent's signature is valid only if an authorization letter from the owner is provided.
Page 2of3
FORM: SSGP 10-2013

Full Pond/
Normal Water Level
Shoreline
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)*:
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

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