20170704 Ver 1_Shoreline Stabilization_20170607

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: $SGP 022017
Shoreline Stabilization Application Form
2 0 1 70 7 04
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 D
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information [15A NCAC 02H .0502(all
1. Owner Information
Name: M.; Ile
Mailing Address: r�151:1 roI Ikwob�_ �n
4a� 1i ,yet 0c,
Telephone Number: 3 e o?Oy 353 1 Fax Number:
E-mail Address: rr:ke_ , 5R&46-ri e I c- - 'nd C6(e)
2. Agent/ Contact Person Information
JUIV 0 7 2017
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:
httr)://www.saw.usace.armv.miI/Portals/59/docs/reRulatory/reRdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name: W, (kecscy
Company Affiliation: Sc>LbAls; de
Mailing Address: Li I" r'3.` I
5aw1-1-. cC�a Ste- vW 2 (_t 5_g2
Telephone Number: 43q 5'79 'W.57 Fax Number:
E-mail Address: t n,(h P -Soul-ii Si dao ne-es • co --
B. Project Information [15A NCAC 02H .0502(a) & (b)l
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 a property (where work is to be conducted)
County: Nearest Town: 1pllk6 fu
Lake/ river/ ocean adjacent to property: '�T�!�1.•�cL
Property size (acres): 0 . G15 G -c -
Subdivision name or site address (include phase/lot number):
300 -�" 4 ktbw '�-a Sz, A, i )
Directions to site - p1jease include road names and numbers, landmarks, etc.: -o
2-.'-.,,\ Lt,0 C�.wr _ U - 614- ov, ci _ LlJ4- �6_,I _ 1..1/", I
Latitude (in decimal degrees) 0 33 Longitude (decimal degrees) -' `I4, o ?7 S+
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Qco; J4 -.l- -k
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): QX ��S�i� SPAce ro-�_ CI G.D "&z
/,-
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:
ego2
Temporary impacts in square feet:
ti
C900
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:
t 3oy -W-
Temporary impacts (temporary clearing, construction corridor) in square feet:
(o o v 4-+,
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): %&2�2
0150
T
/Agent's Signature„ [1 -A Ni CA( Iv)w mfl"*'] Date
Agent's signature is valid only if an authorization letter 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 Level
Shoreline
Plan View
FORM: SSGP 02-2017
La ke
(At Full Pond/ Normal Water Level)
Pf°P°l,o cefb''fl ay "
_ 1
12z)' ( U
+A,le, Iec -s-k
-i}a e I I U1 -�' l. 'eo-
50;1 W'41- y4-"
Lake
(At Full Pond/ Normal Water Level) Existing Dock
30 Ft
3ftx150ft
Below full pard/ NWL
Full Pond/ Normal Water Level
'Ihoreone rr 4ftx150ft
Riprap Above full pond/ NWL
2 h. x 150 h.
additional dearing
' if necessary
E AMPLE
Plan View
Page 3 of 4

Side View
10 ft. bank
height
Side Vi
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
if necessary
Existing bank
R
QUO
FORM: SSGP 02-2017 Page 4 of 4

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300 Hardy Hollow Rd, Semora, NC 27343
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300 Hardy Hollow Rd, ete
a Semora, NC 27343 oa 4
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SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
?i'eLa f Co *1--
LOT NO. 6 O PLAN NO.
STREET ADDRESS:
Please print:
Property Owner: Dk I�
Property Owner:
PARCEL ID
The undersigned, registered property owners of the above noted property, do hereby authorize
(Contractor / Agent) (Name of consulting firnW
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):
0?5 1 '1 f n I /5-o alL Le -,� ,� ,�, 'rk� /UC ar2a 58 -
Telephone: 3A a o cr 353y
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized ig ture
Date:
Authorized Signature
Date:
C 'K S
► 4112-T