20170488 Ver 1_Shoreline Stabilization_20170419

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: SSCP 10-2013
Shoreline Stabilization Application Ford 0 1 7® 4 8 8
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 &Buffer Permitting Unit
a C�G�MG r
1617 Mail Service Center
Raleigh, NC 27699-1617 �N Z017
I. Applicant Information [15A NCAC 02H .0502(a)1
1. Owner Inf rmation
Name:
Mailing Address ,/ Za L_V
�-I- 4M ; 1 -7 f
Telephone Number: [__0(TQ b Fax Number:
E-mail Address: [or,n -Z ce - us-�-
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.armv.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.odf) must
�b�e,attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
lUCm uX�a
AIC', -a g-/ -ZJ<�-
Telephone Number: '70(/ q19-5 (o Fax Number:
E-mail Address: hc,j; r►en+� «rn s r�,c, (<
Person to receive the Certification Approval: -Alu, AA em
1,0
II. Project Information [15A NCAC 02H .0502(a) & (b)1
I. 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: Slt4t') V Nearest Town:wt4 w(�
Subdivision name or site address (include phase/lot number): All tin- Aero c
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude ern deamai ) 3 AP 3+74W8'Longitude fdeamaideVVM 5�` 5 .6292
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Ate &J Ca�&,dicrrL
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Aald- ftr-w 1200 s wbPJ' Aw
- Ile -W woedew,
9. Will -work be conducted from land? [V From water?
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
be]ow the normal pool lake level/ Normal Water Level in square feet or acres:
11. Total amount of disturbance (including all dearin& 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: 6M S �1
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):
3/0/ //-7
T
Agen s Signa f 15A NCAC OZH .0502(fll Date
'Agent's signature is valid only if an authorization letterfrom the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

FI
Norm
S
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

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