20140488 Ver 2_Shoreline Stabilization_20170313

Division of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
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Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
H
Division of Water Resources
401 &Buffer Permitting Unit p � =201?'T 1617 Mail Service CenterRaleigh, NC 27699-1617 MAR 1 ;�
Applicant Information [15A NCAC 02H .0502(a)
Owner I
Name:
Mailing
Telephone Number: Fax Number:
E-mail Address: e-
2. Agent/ Contact Person ormation
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
htta://www saw usace army mil/Portals%59/docsZreguiatory%regdo-.s/Permits%SAivIiPLE AGENT AuTH
ORIZATION_FORKID&I 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:
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

rte
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- pert (where work is to be conducted)
County: �Nearest Town:
Subdivision name o sit ddre (include phase/lot number):
Directions to site -please include
ad namf$e��mbers, landmarks, etc.:
Lora I Ude (decimal degrees)
Latitude (in decimal degrees) g
5. Describe the existing land use or condition of thefie at.thg time of this application
(residential, undeveloped, etc.):
6. Property size (acres): ✓'� ��-s -��
7. Lake/ river/ ocean adjacent to property: /� 1��'�
8. Describe proposed work (include discussion as to how hardening f s oreline has been
avoided, or why it is necessary):
9. Will work be conducted from land? From water? ❑
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the norm pool lak jevel/ Normal W r Level in square feet or acres:
a �
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the norm/al poolake level Normal Water Level and 50 feet land -ward in
square feet or acres: / �O �-3 �
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to be impa" (numb of trees, ins ce):
Owner/Agent's ignature Printed Name Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
Page 2 of 3
FORM: SSGP 10-2013

Full Pond/
Normal Water Level
W
Shoreline
La ke
(At Full Pond/ Normal Water Level)
- ') // � Lz" �' �
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