20170629 Ver 1_Shoreline Stabilization_20170522

4
201 70629
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL OUAL.TY
FORM: SSGP 02-2017
Shoreline Stabilization Application Form
Pro.
Three copies of the application (including attachments) and the application fee should be sent to:
If sending via US Postal Service If sending via delivery service (UPS, FedEx, etc.)
Karen Higgins Karen Higgins
DWR — 401 & Buffer Permitting Branch DWR — 401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information [15A NCAC 02H .0502(a)] 02�@1. Owner Information '`----.�..Lg
Name: ' V\� e. -u P C MAY
D
Y �� I
Mailing Address:
Telephone Number: Q I Q - z 1 S-0cJ 6 -r Fax Number: C( (R - -2,J 0 r -
E -mail Address: ra L, z 4 1 <-- (0 " ,r r, Iw-4­z - _kr.1,b c c,
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter must be attached if the Agent has
signed this application form. (A form can be downloaded here:
http://www.saw.usace.army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
B. Project Information [15A NCAC 02H .0502(a) & (b)1
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, buildings, retaining walls, docks, impervious surfaces, 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.
FORM: SSGP 02-2017 Page 1 of 3

I 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)
n
County: r Nearest Town:
Lake/ river/ ocean adjacent to property: !:�Y ,o
Property size (acres):
Subdivision name or site address (include phase/lot number): '2-0c(
i v\.e�s S ew•. m,,.0. C
Directions to site - please include road names and numbers, landmarks, etc.: IIw� JAW
'
u7. PJ` . C �1- 1 n V�4�t� '� j. V V (� w t
i/\/ Yl�, S oJ' � �► rlyh
La itud� (in de`r�ma/ degreesLongitude (degimal degrees)_ –7`T J 7-7 r
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): V,- e-,;5 S
6. Describe proposed work (include discussion as to how hardening of shoreline has been
7.
avoided, or why it is necessary):
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
14-0.0-4-- xy, S = 7 ty 0- -
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
—7 F_ P2
Temporary impacts (temporary clearing, construction corridor) in square feet:
42
10. 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):
v` ''
11. Signature
_ q-/7
Owner/Agent's
Owner/Agent's Signature [15A NCAC 02H .OS02(f)l Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 of 4
J

12. Please approximately sketch the following information on this plan and provide dimensions for
each item: ,
a. All proposed vegetation clearing 6i4�"tne,T 4-G,,,, �j LA ,,t
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water level PIPVatinn
La ke
(At Full Pond/ Normal Water Level)
in t t 'C' \A ` t+ e,)j' 5 ' .4 a Wax V'- o f ra`a
• • • (�,-tea f s�rlL�fij!) �'1rr►jhft11IL
'��.J� i�- '_1 w,i,�tLII
Plan View
FORM: SSGP 02-2017 1
Full Pond/ Normal Water Level
x x� -IhoreTtne- — —
2 h.x150h.
addltianal dearYg
. V wesmy
E
Plan View
Lake
(u RA Pam/ UM" VftW LweO
Riprap
Existing Dock
/30ft x7h
3hx 150h
Below fLA PM& NWL
<hx150h
_J"t— rut PMW NWL
Page 3 of 4

Al La k6
(tjt Full Pond/ Normal Water
Side View
FORM: SSGP 02-2017 Page 4 of 4

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