20170286 Ver 1_Shoreline Stabilization_20170313

State of North Carolina
Department of Environment and Natural Resources
nxk-l-, Division of Water Resources
15A NCAC 02H.0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: SSGP 10-2013
Shoreline Stabilization Application Form `(j 1 7 0 2 g g
Three copies of the application (including attachments) and the application fee should be sent
to:
1
Division of Water Resources
401 & Buffer Permitting Unit PFtJA
1617 Mail Service CenterUURaleigh, NC 27699 1617 7,`2017
Applicant Information [15A NCAC 02H .0502(a)l
Owner'
Name:
Mailing
Telephone Number: Fax Nurnber:
E-mail Address:
2. Agent/ Contact Person Information
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/SAMP! E AGENT AUTH
ORI7.1\70N For-y.p�.;) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Person to receive the Certification Approval:
Project Information (1.5A 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

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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 prop rty (where work is to be conducted)
County: Nearest Town: --
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names n bers, landmarks, etc.:
5.
6.
7.
8.
Latitude (in decimal degrees)
Describe the existing land use or cond
(residential, undeveloped, etc.):
Property size (acres): Ir -S
n of
Je (decimal degrees)
,ptth time of this application
Lake/ river/ ocean adjacent to property: '11te
Describe proposed work (include discussion as to how hardening 0 shoreline 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 norma�ool la a level/ Normal ater Level in square feet or acres:
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool
I lake level/ Normal Water vel and 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 impacte (number of trees, f s ce):
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: SSCP 10-2013

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Lake
(At Full Pond/Normal Water Level)
Full Pond/
Normal Water Level
Shoreline
a
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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