20170435 Ver 1_Shoreline Stabilization_20170411

20170435
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 0
1617 Mail Service Center P l V
Raleigh, NC 27699-1617 APR 1
12017
DE.-WA
• Applicant Information [15A NCAC 02H .0502(a)J 4ii . : FF --s2OU.c s
1. Owner Information
Name: t)roJley
Mailing Address: 7,5t4, Ate- asvu.,--( mac,
JV- .
Telephone Number: 710z1-5(.O- 33L 5 Fax Number:
E-mail Address: ('ee-1 Mc+hi !9 Qnn )-c..0
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/SAMPL
E AGENT AUTHORIZATION FORM.pdf) must be attached if the Agent has signed
this application form.
Name: ,,"k. C(�..rs®� ) ct„..,s0„_it
tom- ���'�c�v;•meg cV
Con•
Company Affiliation: 0w►teC
Mailing Address: S$65 Pe.S .
Cl i 9-9110
1

1
Telephone Number: ' o3- fel-t-31 to Fax Number: cro3 -531-Ste SS
E-mail Address: rctc.0-rs 3SCe /to-
Person
tomPerson to receive the Certification Approval: 7-ma," C6..441n
• Project Information [15A NCAC 02H .0502(a) & (b)]
• 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.
• Provide a detailed site plan showing property boundaries and proposed
locations of vegetation clearing, structures (buildings, retaining walls,
docks, impervious surfaces, 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.
• Attach a photograph of the shoreline/buffer proposed to be stabilized.
{ (Include a scale of some sort-a yard stick,shovel handle, etc.)
• Location of the property(where work is to be conducted)
County: C- 5d 0" Nearest Town: e[oke vv--
Subdivision name or site address(include phase/lot number):
305 CoTe. .4 -# - ` ,t .A.a .•c• ag-o a
Directions to site- please include road names and numbers, landmarks, etc.:
744- 6-3K4--i-- o A4 aF SP RS Oeqo Sew k-?ci v4--4-Q , ., -.+tea. c'9h-
oet ex) Le,,.+tr Ar,ut-Si-co. . (I4 Wy 9-73) , 4.0c.A. 1e_ on
ShivN.vbutr L.n. , 3c 4-. *aka + 4ci j. rilyvk4- o C°17Q.. Avtvs+
�l. / Lek 30 Witt on 1tr-+
Latitude(in decimal degrees) 36n.(02"N Longitude(decimal degrees)
►°O.1.OS.sil"w
• Describe the existing land use or condition of the site at the time of this
application (residential, undeveloped, etc.): (`c s i c Y. .l /- -kkre.-
hneke. cift
• Property size (acres): 0• (o4
• Lake/river/ocean adjacent to property: Gak-e._ GIYI,�e
2

• Describe proposed work (include discussion as to how hardening of shoreline
has been avoided, or why it is necessary): Hpo.otc (ctk.e Ora-cc-
d laccpx" bcAAA-s eve_. r cwt.;Ap-ck <k
• Will work be conducted from land?LA. From water?
• 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: . Proms A.or.t•-(
3' ki k x 143' I oil x 3'1-L ,k
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: /7%0 sr, fA
Cow44-t'.-5 Acccsc ro��
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):$v1A(I ctdetr+c< /"t'; 'c+�:o n PPro x. s/s�-/1"tr s/
»1 eft
off p
OK- N5 1' 5T dt o-C f ror,r-i/, /vn tft .5 o vi ACCtS-5 FoaaL +0 b.€- r'-e-n90 11-(-4--
7_/7 —r/7
Owner/Agent's Signature* [15A NCAC 02H .0502(f)) Date
*Agent's signature is valid only if an authorization letter from the owner is provided.
3

P--... 14 `-) U :___ _____ ___ _ _--Elicreso t R::r:erPeint
Home Insert Design Animations Slide Shah Rene: filers Laseitiche
-i Layout- - _ _ _ .. D,� '-'
--i Reset .L,.-L�S
Paste 11412 _ ,,., _ _a — h 1�{ }
e11tS,- ...�Delete _ .. ..
i Lake
(At Full Pond/Normal Water Level)
BGims✓ Fu//
3 f �'
/ / ' f n 2 A/7 K /1/3 / >1'�x , - - --
' � ' 7� 1—xa% fall -
�pr0,a l 4-
.7 / u�r
Full Pond/ . ' ---�..—. .
Normal Water Level 3
-w . __- .. ; - . M m 1V- x. •-
- Shoreline 9y�' ./z'
F ' 4etcs5 levaa,t
,,,, )
11_
- 4421
Sta. 4
Slide 4 of 'Mee Theme' v
i _.. 'I ii -- a _ - i
Please approximately sketch the following information on this plan (provide
dimensions for each item, such as 10 ft x 100 ft)*:
• All proposed vegetation clearing
• Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level
elevation
• Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level
elevation
• Location of any proposed structures such as buildings, retaining walls, docks, etc.
• Location of any excavation or dredging below the Full Pond/ Normal Water Level
elevation
4

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• Location of construction access corridors
5

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 3 0 PLAN NO. PARCEL ID:
STREET ADDRESS: 305 3 pe_ v,s+ 1wooA-4-i J -%at
Please print: //
Property Owner: 9f Z6 (,e ,1 Oa-5
Property Owner:
The undersigned, registered property own s of the above noted property, do hereby authorize
, of �7�-i•us o t 5 f
( ontractor/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):
a hes
Telephone:7 Q 3 3 ;__S
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
J
Authorized Sign.t 7 Authorized Signature
Date: 1� / 1 Date: f 7/7

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