20170712 Ver 1_Shoreline Stabilization_20170607

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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 2 0 1 7 0 7 1 2
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)] �\
1. Owner Information/y . 1
Name: �'�tJ� ®efI�
Mailing Address: YPm Lif"i�I� D✓����
�c K 42!1 IV?, 9/ 9G� 1 6 � 7
Telephone Number: 1% M / Fax Number:
E-mail Address: Mot f ee SP 0✓l 60 A eO f'V1
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/regulatory/`regdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name: ^4-rrHnMO I ,/ yn
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
(044
'a % &rIPr? 6 sf ytQ /?tel
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7 3 / Fax Number:
t_ �-f-%� SD�{s�iSO✓lBd�cls'Li ap - !o
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.
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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.
Page 1013

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: PleyC oyq Nearest Town: Yews 10 KA
Lake/ river/ ocean adjacent to property: _ YZ I) 66<e—
Pronertv size (acres): ^ `1 J I—c
Subdivision name or site address (include
Directions to site - please include road names a
I+- M + 2,'0✓7 t p -"of PW
number):
Coo r7
py'
numbers, landmarks, etc.: 17'h✓ .S%
Latitude (in decimal degrees) .3 6, LIPy116 hongitude (decimal degrees)
75,o1q�k
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): 9t-0Si eiPel 1111ft-
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): A-QPli+1 f n Ay A+'f'P A eks 7b iteee
S O"it N -Ole hro rn cevs i✓i
7. Will work be conducted from land? Rr_, 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 Is, etc.) in square feet:
�00 -r700 1-6 re
If
Temporary impacts in square feet:
AK u A.e,
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent,irMpacts (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/ Norm I Water Level and 5
feet landward to be impacted (number of trees, for instance):S
6✓1t C -,r K 0 ✓i I LhQr 1
11. Signa
Owner/Agent's Signature` [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

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
Lake
(At Full Pond/ Normal Water Level)
t(P ff A -P
-3f'-r- rCo w
ftl'� 4 6 1 rj C C/7 () C- I
6 Y\A�)
Lake
(ft W1 Pono NorrrW wmr Le I) Existing Dock
/ 30fta7ft
E AMPLE
Plan View
FORM: SSGP 02-2017 Page 3 of 4
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E AMPLE
Plan View
FORM: SSGP 02-2017 Page 3 of 4

La ke
(At Full Pond/ Normal Water Level)
Side View
t 'IPI 0V r,�t fo�
IC4 A9 6,(4 F/1Powf/etAAe
06
U-
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
ff necessary
Existing bank
10 ft. bank
height�'�12'
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FORM: SSGP 02-2017 Page 4 of 4
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VICINITY MAP
JOHN W. woo(
D.B. 256, P. E
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LEGEND
NF • NAIL FOUND
NS o NAIL SET
IF • IRON FOUND
CAROLINA POWER
A LIGHT COMPANY
CONTROL HYCO LAKE
CORNER 420'
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