20170628 Ver 1_Shoreline Stabilization_20170522

State of North Carolina
2 0 1 7 0 6 2. Department of Environment and Natural Resources
Division of Water Resources
Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL QUALITY FORM: SSGP 02-2017
Shoreline Stabilization Application Form
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 a
DWR — 401 & Buffer Permitting Branch DWR — 401 & Buffer Permittin
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604 MAY 2 2
A. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Telephone Number: ,?Z a2-47 - t{12-1 U Fax Number: 7 5 q9
E-mail Address: pc I + tO t Iona . c C,ryl
2. Agent/ Contact Person Information
it&lX('%'
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: Fax Number:
E-mail Address:
B. Project Information [15A 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, 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

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:, +_ "_ _^^'4-4-41
County: r
Lake/ river/ ocean ad.
Property size (acres):
Subdivision name or
C' L � Y, va na�;jl;�1 �aua� rna.•�-naj /fira©a.h.t� rn2r,"�Q rnbSrn Si"n n�1(�','Na
Directions to site - please include road names and numbers, landmarks, etc.: 0-rej
i2Q / ^.I^._,.._r" I%-72 Cnnn ..,..._P.0 1 ai\ n L..r0..♦Anr.w 10
Latitude (in decimal degrees)
Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Fe -0 4`ecy-\
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): F; 1) ` 6c,, e Lnoc 'b oakz_+ 7
7. Will work be conducted from land? �9_ From water? ❑
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:
r
Cl -.,..,,1,. �/'� . rn,.rnn-::.r. /fih �r?r.n,.♦ '2,1%A` ,nl.r.�Y,.`.itr+sr.,% <m
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
manent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
,;n 15 , . SQ ue? I', 2;M - Ucc k I. gc Mn 00'
Temporary impacts (temporary clearing, construction corridor) in square feet:
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):
(-.'t-\ fA n cz % v ^r%1 v _ PbAif. r: ( irAe4d 01 M 1- L)dles
11. Sign
(Y--//
-A-1�
Owner/Agent's Signat re' [15A NCAC 02H .0502(f)] Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 of 4

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