20141101 Ver 2_Shoreline Stabilization_20170525

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 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
DWR - 401 & Buffer Permitting Branch DWR - 401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street CA N
Raleigh, NC 27699-1617 Raleigh, NC 27604m 1' •
A. Applicant Information [15A NCAC 02H .0502(a)] o ��
1. Owner Information / � jVT%
Name: �/®� fJll o
Mailing Address: I lkwAj /f'l/!/ CT
_ cle-14L, AJ Z- C52-74-11)
Telephone Number: 9/ 1 'ii /30 Fax Number:
E-mail Address: DCte- 04-11MDI0 S , (Dm
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:
htto://www.saw.usace.armv.mil/Portals/59/docs/reeulatorv/readocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name: DCAV lf) �21s1(V1�i�� I��Wti��P� �_C,�✓�d�,�C��n:'
Company Affiliation: 1'e -t1 wL cz-er-
Mailing Address: ?- C) . 'St VC 1''1
l ✓yl ber I QL4
Telephone Number: cj l�j-Q-�j�C`�2 Fax Number:
E-mail Address: 7✓1(+'1� r' �1(;1Sf�i �11�1li� Biu-:+ 00• L�,�-,
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 property (where work is to be conducted) ,,
County:�Racsc r Nearest Town: �).emora_
Lake/ river/ ocean adjacent to property: l-��f G C>
Property size (acres): � - 1-11
Subdivision name or site address (include phase/lot number):
—r -Ke- Ret e rvi_
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (in decimal degrees)
Longitude (decimal degrees)
Describe the existing land use or conditi o -f the site at the time of this application
(residential, undeveloped, etc.):
Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 'CDI( -e'—' 0r'>'5,0 A— t4- eoso
7. Will work be conducted from land? R/ 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:
15QTCT
Temporary impacts in square feet:
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:
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):
�0 Lan I
11. ' natu
LAI t A, _SJ_
Z C�
Owner/Agent's Si tvidlonly
4 [15A NCAC 02H .0502(f)l Date
Agent's signature iif an authorization fetter from the owner is provided.
FORM: SSGP 02-2017
Page 2 of 4

12. Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
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 elevation
Full Pond/ Normal Water
Shoreline
Plan View
FORM: SSGP 02-2017
Lake
(At Full Pond/ Normal Water Level)
. j�' � 6CU-,e
' ���0
Full Pond/ Normal Water L
r 'Ihoreone r
2 ft. x 150 ft.
additional clearing
' if necessary
Plan View
Page 3 of 4

r
Dui
r` b7VQj)
.. Lake
(At Full Pond/ Normal Water Level)
N
C
M
ET-
&-
L O
O -r
Z to
C
Side View
LL -
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
if necessary
Existing bank
10 ft. bank a
height 0�iQ'
COQ
Q
r
MPLE
Side Vi
FORM: SSGP 02-2017 Page 4 of 4

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