20170744 Ver 1_Shoreline Stabilization_20170616

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DUKE ENERGY EXCAVATION PERNIIT APPLICATION FORM
FOR DUKE ENERGY USE ONLY
Duke File No.
Application Fee $ Security Deposit $ Check * Date Recv'd *3Initials +' j
Date of Duke Energy Lake Services, applicant and/or contractor on-site inspections Dated � 0 i -t Initials K� n� 11
Date Final Protection/Avoidance Area Markings Field - Verified
Approved to Start Work By *
Date Completion Required
Date Passed Closeout Inspection*
(prim)
— Date of Any Approved Extension
Initials
Initials
Date
(Sign)
- Initials
Any Stop Work Orders or SMG Violations*? (check one) ❑Yes ONO (If Yes, explain in PART V)
Date Deposit Refunded Initials Date Permit Database Updated Initials
t Forward copy of approved application (all pages, plus any attachments that Duke Energy changed) back to applicant
with Approval Letter and highlight any changes. File copies of Approval and Close-out Checklists and any Stop Work
PART L - APPLICANT INFORMATION (Please Print)
Name 'Roc gey Kli S e`r"
Lake Address A O � / 7 ST�J A J't D r/1i C,U�L ✓ %
C'QrNcl� ws nlC. o i
� d
Contractor Company
Af
Telephone 7� / 9� • T�
Mailing Address
(Ifdi„$erent) Jti I.,r 1z
lid � vlzD
Contractor Contact Person Cki P fbrr 13AC.5 J Telephone
1 TING
LAKE LOT INFORMANT QN
Lake r County _ We e C K. Cityrtife • 5 State _Tax Map No.
SubdivisionAA i4__ Lot/ Section No. Lot SiuO. qJ5 Acres
Are there any Co -Applicants*? (check one) L7Yes ONO (If Yes, include names, addresses, phone nos., lot nos., lot
sizes in PART V – ADDI'T'IONAL INFORMATION) * Co -Applicants exist when the proposed work is being done under a
single application, wr11 be performed by a single contractor as one continuous project and is done to benefit multiple owners /
lease holders of project -front properties within a single development. The check for the application filing fee and security
deposit should be from the party shown as Applicant and not several chocks from the Applicant and Co -Applicants.
Do not continue the application until an on-site inspection has been conducted between a Duke Energy Lake Services
Representative (DELSR) and the applicant and/or the excavation contractor. NOTE. Initializing this portion of the
application by a DELSR in no way consdMa approval or eminent approval of the aacavation or any other lake use
Date of on-site inspection Ij 3V t Initials (Dake Energy) d k (apphcant/contractor)
Duke Energy
Excavation Program
Page 1 of 14
rev 9/19/14
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application 113 l0.docx

DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
PART 11 - DESCRIPTION OF PROJECT
1. Type of excavation: (check one)New excavation 0 Maintenance excavation
2. Purpose of excavation (check one)Boat Access Channel 13 Waw hitak taftwaterDischargeCliannel 0 odd (4vdtfy l
3. bake uses categpry: (check one) ������,,�� OResidential Marina OCammercial Marina
*ubHc OOther (cif!')' 9/1
&0 , 5'c, .
4. Max. Excavation Area Dimensions (ft): Length _3� Width n � dtnrensions to #4)
(Note: include additional area dimensions if necessary so nsWMw to i6 .low equals
5. Vohune of E=Rvated Material (TOTAL for the project): _ 7V Cubic yards
L
6. Type of material removed (applicant determines byfield sample rpracticoo:0.90-7
7. Excavation site area C,- Q 7i Acre (s) Disposal site area: n. o Y� Acre (s)
equipment staging area): 0.1 g) Acre (s)
8. Total pisturbed Area (tnchkling equip
9. Does the project meet the requirements of the applicable General Permit? (check one) 314cs ONo
10. Do you claim title to the disposal area? (check one) VOes Moo
11. Do you claim title to the equipment staging area? (check one) �es ONo
12. Are there any wM t facilities within 50 fast of tier proposed area? (check one) OYes �1Vo
(If Yes. specoy)-
13. How Will the excavated material be entrapped and the controlled? 4e .see control P� and ane design): W 0r K W; ft � C. A p G p -t 6 t f'�t4�:.1 e o b y
14. Type(s) of excavation equipment to be used:
15. Will waters or wetlands be crossed in transporting equipment to or from the site? (check one) Dyes ilo
(Ifyes.n
16. Will rdw Water re•tater, the reservoir? (Check one) Dyes 0o QWA (If Yes, specify povd(s) Of m-Im y and
shots' out Ewavadon dna Drawfg)
17. Is thane an existing facility (eg. pier) that access is being maintained to by conducting the excavation? ,fes ONO
(,d yes. specify the casttng ptrmtt number: If No. include a scaled drawing of the proparedi�gY)• Permit /Twp , S
18. Total planned duration of the work (Indude fbw equipment mobdlbWom excavation through f -W miilg JI Wer Cn P t°
complete): START! liyi FAIISH
(Yarn) N(t's)
Duke 1w, Page 2 of 14 rev 9/19114
Excavation Program
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application 113 10.docx

DUKE ENERGY EXCAVATION MOM APPLICATION FORM
PART IL (ComInued)
.. � .114 � � .... •. � � � 1_ • �
Complete the following table including all land areas within and immediately adjoining the dishubed area:
(check all that apply)
�
Metkod ("1
Avoid (A) or _�
F�
Work Area Dwss ID
a. Marshland, swamp, ponds, beneficial
aquatic vegetation or odw potential wetlands (circle all
that apply)
/
A[IA
I
b. Buffer Zones (spec'if'y width & source of
„aqui eme„O
'
�D N7� W t `
c. Environmental Areas as identified by DukeEnergy
d. Natural Areas as identified by Duke Energy
, I
e. Historic properties (8pec(ji')
I(II
fi Rare or tl (specify)
Duke Energy Page 4 of 14 rev 9/19/14
Excavation Program
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DUKE ENERGY EXCAVATION PERMIT APPLICATION FORM
(check all that apply) AMUWorh Arm Dw ID
a Buried gas, watce, sem, communications , / /�
or electric lines (ctrcle) /v(
L Impact Minimization Zones as identified by
D/�5ZEnergy
L Other areas requiring spocific avoidance,
protection or mitigation (specify)
* " entity or that performed the identification and how it was pkrys MUY mwW (e.& Duke Energy (John Doe)Mink and piuple dotted tape,
For Field IIY' column, specify ty person ped the rote<:tion/avoidance area
Corps of Eng, (John Smithy yellow flagging). For "Work Area Dwg ID" column, show the symbol that is used on the drawings to idendfy p
** List and attach mitigation plans
Duke Energy Page 3 of 14 my 9/19/14
Excavation Program
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DUKE ENERGY EXCAVATION PERNIIT APPLICATION FORM
C. APPLICANT'S SIGNATURE t %G, k / _ „S
Comments: / �l D'��
Eve 1,404 C -r e -A l" -70X04 ST-*J,D w tj C*-.
Applicant Name
Applicant Signature*
Co -Applicant Name (prim)
Co -Applicant Signature*
Co -Applicant Name (print)
Co -Applicant Signature*
Co -Applicant Name (print)
Co-Applicent Signature*
Co-Appiicaut Name (prim)
Co -Applicant Signature*
Co -Applicant Name (prim)
Lot # L
Date
Lot #
Date
Lot #
Date
Lot #
Date
Lot #
Date
Lot #
Co -Applicant Signature* Date
*Per my sigmature, the imformation provided in tins application is correct to the best of my knowledge.
BEFORE YOU MAIL THE APPLICATION TO DUKE ENERGY LAKE SERVICES ENSURE YOU HAVE:
• CHECKED THE INFO THOROUGHLY
• MET ALL REQUIREMENTS S FOR A COMPLETE APPLICATION (see cower letter 4 WIication paAage)
• INCLUDED A SINGLE CHECK TO DUKE ENERGY FOR THE APPLICATION FILING FEE AND SECURITY
DEPOSIT
• INCLUDED ALL AGENCY PERMITS OR COMMENT LETTERS AND RESOLVED ALL ISSUES RAISED
• INCLUDED ALL REQUIRED DRAWINGS (INCLUDING PROPOSED FACILITIES), PERMIT # FOR EXISTING
FACILITIES, SURVEYS AND PLANS
• INCLUDED COPIES OF DEEDS AND AUTHORIZATION LETTERS
Duke Energy Page 6 of 14 rev 9/19/14
Excavation Program
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application 113 I0.docx

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
p 15A NCAC 02H .0500— Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: SSGP 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
1617 Mail Service Center
Raleigh, NC 27699-1617
I. Applicant Information [15A NCAC 02H .0502(a)1
1. Owner Information
Name, Rodney & Kathy Kiser
Mailing Address: 20417 Staghorn Court
Cornelius NC 28031
Telephone Number. 704-892-7060 Fax Number:
E-mail Address.. [e-mail]
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
h aw usace. P rz r tato r d Permits SAMP E, PENT RUTH
RIZATION FORM.pdf) ust be attach d if the Agent has signed this application form.
Name: -4
Company AffiIlation: G C �✓c '� c �^/
Mailing Address: i >
V;
Telephone Number.70.6„CD ../� j Fax Numb r:.70__ L
E-mail Address: G�c SCAB s t� b-eAo-%' -N
Person to receive the Certification Approval:
II. Project Information f 15 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, structures (buildings, retaining walls, docks, impervious surfaces, etc.),
rip rap, excavation or dredging below Full Pond/ Normal Water Level elevations, and
FORM: SSGP 10-2013 Page 1 of 3

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 property (where work is to be conducted)
County: Ll Nearest Town: rtJ� ws /
Subdivision name or site ad ress (in Jude phase/lot number): 20*/7 SM-We-
Tl�J�-ff�rida P in -
Directions
n -
Directions t site - please indlude road names..and nu//m%bers, landmarks, etc.: Z
,04-.., ::�T/4-A X A L- Al /4 --
Latitude
--
Latitude (in decimal degrees) 5 . 49 0� Longitude (decimal degrees),Y—O •2l O 5 6 )1 7
5. Describe the existing land use or condition o the to at the time of this application
residential undeveloped, etc.: Y'C5(44,Al Ho
6. Property size (acres): ©• 47 5
7. Lake/ river/ ocean adjacent to property: _1+Ke OrIY) AA/
8. Describe proposed work (include discussion as to how h/a,,rdeni g of shoreline has been
11
avoided, or why it is necessary): y -e -J � t �YI d A- LS S
9. Will work be conducted from land? ❑ From water?
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake level/ Normal W=*er Level in square feet or acres:
l o X S _' X .34 r X x y- r
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres:
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50jj
feet landward to be impacted (number of trees, for instance): rel SS See �7'a�
Ali ,/�lSL2 4AWA P -d
/Age s Signature# Printed Name Date
115A NCAC 02H .0502(f)l
`Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Full Pond/
Normal Water Level
an am w
Shoreline
1;fOtICI
Lake
(At Full Pond/ Normal WalI,e
j r
51' � -,4 A �o`
�7t� cu. yds
Podoveq K Sir
070��7 ST horn( C�-
Cortid;us, NC -
99 -631 x-9-63 j
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft)*:
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.
S. 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

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THEPROPERTY OF RODN L. TUBER AND WIFE THY W. tSER
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