20170208 Ver 1_Shoreline Stabilization_20170217

kw_ State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
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
Raleigh, NC 27699-1617
Applicant Information [15A NCAC 02H .0502(a)
1. Owner Information
Name: P�;"(
Mailing Address
Telephone Number
E-mail Address:
M4. el_ l '� ti r Z.
2. Agent/ Contact Person Information
Fax Number:
2 0 1 70 2 0 8
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. df) mustbeattached if the Agent has signed this application form.
Name: %� a aln /f 1p lc
Company Affiliation: A14 G
Mailing Address: lU7S5 W »�� �c k y-(4
Ni ur-woce� %V L 2 Sr) Z Y
Telephone Number: 719% C1 5-5 Number:
E-mail Address: is�rue-�i'fd'�, Ec? a y��o � C��
Person to receive the Certification Approval: /VaPut A/M 0-n
8
II. 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: ���an�gv�ne-ry Nearest Town: IV (T
Subdivision name or site address (include phase/lot number): Me, )0e n tnI5,
2Z q Gr 4t i,^ e r 4 -
Directions to site - please include road names and numbers, landmarks, etc.: T"Pw
r#J h 4- &,, � 7 3 hw v o -P S' -P 2 Li' - 2 7 fin 7Livrr� t�i4 Af r�
B
JJ y� 7] q I
Li l �.ys/ �Ji"+�c9z ��tK v-rv- y- �' a %ti i �a 1 W l'�`t�✓ her lam
r G % f m k- C ra ivy 4,r �, IUk" -e- 1,, is 42-
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.): ry—S % �'en �' 4, w#i2­e✓ C wwc�r�n-i
6. Property size (acres): a /�
7. Lake/ river/ ocean adjacent to property: Le, 'k %'� � I -e'rY
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): $✓iu�rc ��%� c ` %&,ycl c
y c �
> �cz Asa bc sly c- c! �,d sor►
9. Will work be conducted from land? Vf From water? EI
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:
M kv b -e- 2- Gc-I s 9, -r-k .a,- --Pt, // 'bond
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: cwuwi ci s P�
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): /5 ,Leets
rec
Owner/Agent's Signature
Printed Name
[15A NCAC 02H .0502(f)1
•Agent's signature is valid only if an authorization letter from the owner is provided.
Z-/3/ 1-7
Date
FORM: 55GP 10-2013 Page 2 of 3

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 6
PLAN NO. PARCEL ID r a S 7S % LI /-1 3 7 qz16;
STREET ADDRESS: 2 Z Ll Crayd Al L r-1-
2
Please print:
Property Owner: C: he-> en. l c 6 e, e -
Property Owner:
W-1
The undersigned, registered property owners of the above noted property, do hereby authorize
111 OAkak ff'�h'm G of
(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):
hs J- L/ 1 'k""4 Pl-e",rn,� Al C 2
Telephone: _70 LJ 2 2 S Z 7
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature
Date: Z f ► 'I
Authorized Signature
Date:

Fl.
Norma
SI
lake
(At Full Pond/ Normal Water Level)
<,— 3 6 ----)
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