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State of North Carolina
Department of Environment and Natural Resources
DW Division of Water Resources
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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
1. Applicant Information F15A NCAC 02H .0502(a)]
1. Owner Information
Name:
Mailing
Telephone Number: 7e* q� 3 Z.65-1 Fax Number:
E-mail Address: c4 o r; +c h i&_ C' Wy.1 25 w—,i e N T
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.mil/Portals/59/docs/repulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORiZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Person to receive the Certification Approval:
11. Project Information [15A NCAC 02H .0502(a) & (b)1
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 3

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: .J Ti Nearest Town: L'/j%�-tel C
Subdivision name or site address (include phase/lot number): 1 i/,=' U
�o T ��
Directions to site - please include road names and numbers, landmarks, etc.:
5.
Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): IC I ---I> 15J Tl
6. Property size (acres):
7. Lake/. river/ ocean adjacent to property:
LG
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): G `c X )� 7-,,,'J J1 0,-J I Pe''� li 6v 7--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 Water Level in square feet or acres:
e-_ 6, �=" i -7r., 'Y
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level Norma Water Level and 50 feet land -ward in
square feet or acres: 16_2-5.Fl /� _7
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): ty%0
-/- 1/ l?
Owner/A nt'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 10-2013 Page 2 of 3

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kwRADIN36108 NC 740 Hwy
Albemarle, NC 28001
Betty Andrews
49449 River Run Rd.
Albemarle, NC 28001
t fi.t
6/26/2017 16
Phone # [phone] Fax # [phone] [e-mail] www.mooresgrading.com
Description
Qty
Rate
Total
Shoreline (76 ft X $75.00/ft = $5,700.00)
76
75.00
5,700.00
$5,700.00
Phone # [phone] Fax # [phone] [e-mail] www.mooresgrading.com

.0
Immlow
Z
WO
X4.
Immlow

Lake %IL -L SAY
(At Full Pond/ Normal Water Level)
,G, 1 "; T
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 -EYC 15TiA/6 Tt 3 e 5 C-- f:
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. 2 r,BGZQA)
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
Lv/f-72�.
6. Location of construction access corridors
FORM: SSGP 10-2013 Page 3 of 3
4--76
Full Pond/
Normal Water Level
purRA P 2'
w
Shoreline
K Z'
w r TC
yv� v L C 14
4'- oCo
�
w�D
O
v
°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 -EYC 15TiA/6 Tt 3 e 5 C-- f:
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. 2 r,BGZQA)
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
Lv/f-72�.
6. Location of construction access corridors
FORM: SSGP 10-2013 Page 3 of 3

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