20170749 Ver 1_Shoreline Stabilization_20170619

DWR
Division of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H.0500 —
lits Certification, Shoreline Stabilization
y FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Four 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 2 0 1 7 0 7 4 9
Raleigh, NC 27699-1617
tCF
(S�1. Applicant Information [15ANCAC02H.0502(a)] 9 20171. Owner Information
Name: -F : N S rn ti�
Mailing Address: 3 FER ERMITT
Telephone Number: I-5_40 Fax 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:
http://www.saw.usace.army.miI/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must b¢ attached if the Agent has signed this application form.
Name: s -k v -P $o to v. �J
Company Affiliation: },i e5, Q u a
Mailing Address:
Pe Zo
&t'r,) n C ).: 5(" -i�
Telephone Number: 4 �� �6$� Fax Number:
E-mail Address:
Person to receive the Certification Approval: -? Al L
11. 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, structures (buildings, retaining walls, docks, impervious surfaces,
FORM: SSGP 10-2013 Page 1 of 4

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 property (where work is to be conducted)
County: f " hc+ n1 i L. i► Nearest Town:
Subdivision name or site address (include phase/ /lot number): L,4
Directions to site - please include road names and numbers, landmarks, etc.: f= n,
_?"aP71 tom, 5_ a- '��T�N %�.yhr
L�Ft oc, �hcj�aNK� �D Ti�tN �Hry 1-p �N Sa9amcrO pt d Pvz_
mi l� apy---
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): t b u 7 ' N 1 c f u c-4 L o 5�. � � yi P�/ gp,47V
-6. Property size (acres): C, . 4 q `((
7. Lake/ river/ ocean adjacent to property: L J k. /2e ,f z
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): ti -p a` To to
�0 alll i9�af� T
9. Will work be conducted from land?[ r� From water? ❑
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake level/ Normal Water Level in square feet or acres:
c3 7X01'm41 PV_J AI.P A&"
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: 3-5-475 q-cf -i
12. 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): -/16
ra F-ew 13L&;0h05 e N
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: SSCP 10-2013 Page 2 of 3

�I
l
is
10
s

Full Pond/
Normal Water Level
Shoreline
Lake
(At full Pond/ Normal Water Level)
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:x-245
sc9.e�rroY�
Dr
60 Sac -Y'n-' pr.
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.
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
5. Location of construction access corridors
FORM: SSGP 30-2013 Page 3 of 3

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