20170673 Ver 1_Shoreline Stabilization_20170530

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
3,5A NCRC (32H ,0500 — Water Quality Certification, Shoreline Stabilization
Division or Water Resources Y _ FORM: SSCP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit 2 0 1 TO 6 7 3
1617 Mail Service CenterD 19@ g o n g
Raleigh, NC 27699-1617 D
.� MAY 3 U 2017
I. Applicant Information
1. Owner Inform Aon ^ DEA -
E 8 -Wq
401 g FF RE O R ES
P TTIN
Name:
Mailing Address:
Telephone Number: ��% ��%fidFax Number:
E-mail Address:
2. Agent/ Contact Person information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Person to receive the Certification Approval:
Fax Number:
ll. Project Information
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, structures (buildings, retaining walls, docks, impervious surfaces,
Page 1 of 3
FORM: SSCP 10-2013

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 prope where work is to be conducted)
Nearest sown:
County:
Subdivision name or site address incluu phase/lot number): —
Directions to site - please include road naes d numbers, landmarks, etc.:
5.
Latitude (in decimal degrees)
Lora Dude (decimal degrees)
Describe the existing land use or condition of th +ie a .1h time of this application
(residential, undeveloped,��
etc.):_
6. Property size (acres):
7.
Lake/ river/ ocean adjacent to property:
S. Describe proposed work (include discussion as t hoW ha
avoided, or why it is necs�obry): '
9 Will work be conducted from land? [ From water?
shoreline has been
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the noormalll fool lake level/ Norrmal ter evel in square feet or acres:
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal ppol !ak level/ Normal Water Level d feet land -ward in
square feet or acres:
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to be impacted (n
Owner/Agent's Signature
Printed Name Date
Agent's signature is valid only if an authorization letter from the owner is provided. Page 2 of 3
FORM: SSCP 10-2013
A

-i:t: ��3r4p1
Itlorrnaj _ _t_r Level
shoreline
C
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ftx 100ft)*:
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

1
25
PB 24/68
15.67'
15.67' -
LAKE MLERY
......I ..._r \_.._ -- -- - - -I
LINE TABLE
LINE LENGTH
BEARING
Li 20.95
S28'44'29'W
L2 84Ai
S35'21'48'W
L3 20.78
S36'27'03'W
27
P8 24/68
.15.6
,25.2
38.0'
GRAPHIC SCALE
30 60 120
( IN FEET )
I inch = 80 ft
CA/P
"A.
L-3751
.n
LAKE TILLERY
240
Piot Plan of: REV -
Jeffery
V -Jeffery S. Lot 26, Eagle Pointe, Phase 1
For: Dan R. Ellis Jr. & wife, Cynthia G.
Gordon Legal Ref: DB 1537 PG 821; PB 24 PG 68
Norwood, E. Center Twsp., Stanly County, N.C.
Scale: 1" = 60' Date: 28 March 2017
Surveying Jeffery S. Gordon, PLS, L-3751
1394-B Walkup Ave, Monroe, NC 28110 [phone]
Dwa. File: #5\D—Jordan\Dwq\26—Eaale—Pointdwq

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