20170287 Ver 1_Shoreline Stabilization_20170313

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
DWft 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:
1
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Applicant Information [ 7ti "JCAC 02H .&-,
Owner Information /
Name: L -
Mailing Address:
Telephone Number: O = --�"�' Fax Number:
E-mail Address: P r �
2. Agent/ Contact Perso nformation
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
h-tp://www.saw.usace.arr-..y.rr,i!';icrt,,is!'59 occc /regui@tory/reg:_ —2,'Perr�its/5fAiVIPI E AGENT AUTH
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 .C1502(a} (b1]
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 prope (where work is to be conducted)
County: ori Nearest Town: ¢
Subdivision name or site a ess (includeLphhase/lot number):
Directions to site - please include road nam s and num rs, I marks, etc.:
f�,a!
r
I
Latitude (in decimal degrees) Loll g �Ude (decimal degrees)
5. Describe the existing land use or condi ' n of the at. he time of this application
(residential, undeveloped, etc.):
6. Property size (acres): ✓`� �'�--5
7. Lake/ river/ ocean adjacent to property: r�P
8. Describe proposed work (include discussio as to how harden" A shoreline h s been
it is necessary): ��'P
avoided, or why �---
' cr c� /fir% ! ✓�S cod!
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 normal pool lake level/ Normal Water �Le�vin square feet or acres:
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool laYe level/ Normal Water Level a 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 ber of trees, for insta ):
Owner/Agent's Signature
Printed Name Date
Agent's signature is valid only if an authorization letter from the owner is provided.
Page 2 of 3
FORM: 556P 10-2013

FL
Norma
SI
Lake
(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