20170964 Ver 1_Shoreline Stabilization_20170803

a
Duke Energy Excavation Permit Application Form
FOR DUKE ENERGY USE ONLY
Duke File No.
W y
Application Fee $ Security Deposit $ Check # Date Recv'd Initials
Date of Duke Energy Lake Services, applicant and/or contractor on-site inspections Datet. 7 � 7 i 0 Initials. j 2ejjLl
_
Date Final Protection/Avoidance Area Markings Field - Verified
Approved to Start Work By * :
Date Completion Required
Date Passed Closeout Inspection*
Initials
trruitt (sign)
Date of Any Approved Extension Initials
Initials
Date
Any Stop Work Orders or SMG Violations*? (check one) ❑Ycs ❑No (trYes, explain in PART V)
Date Deposit Refunded Initials Date Permit Database Updated Initials
* Forward copy of approved application (ail 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
Orders with annlieatian.
Part I. Applicant Information (Please Print)
Name 14 oil 6wro r 1 Telephone
Email address:
Alehrage- I u xu.vy kovwc5 .
Lake �O d resss�- n MailingOAddreess (if different)
P � tIFZ47
1'Ilo 55 -vi Ae- W- ;t-8117
Contractor Company C 13 C 57-W d- f
Contractor Contact Person / f36tid I e- s — Telephonet)
Contractor Email Address: e-, hr f-)tf 95 p w ', Nd S, � A -M . A[e-
LAKE LOT INFORMATION
Lake County_ -t G� City00rG$d; 4- StateAfG Tax Map No.
Subdivision kv- Lot / Section No.
Duke Energy
Excavation Program
Page 4 of 14
rev 2/6/17
E

Duke Energy Excavation Permit Application Form
Are there any Co -Applicants*? (check one) ❑Yes No (If'Yes, inchide names, addresses or
lot numbers, phone numbers, lot sizes in PART V — ADDITIONAL INFORMATION)
* Co -Applicants exist when the proposed work is being done under a single application, will 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 checks from the Applicant and Co -Applicants.
Do not continue the application until an on-site inspection has been conducted between a
Duke Energy Lake Representative and the applicant and/or the excavation contractor.
NOTE. Initializing this portion of the application by a Lake Representative in no way
constitutes approval or eminent approval of the excavation or any other lake use permitting
activity.
Date of on-site inspection 61 21 1
Initials (Duke Energy) j_l(a�� (applicant/contractor)
Duke Energy Page 5 of 14 rev 2/6/17
Excavation Program

Duke Enersy Excavation Permit Application Form
Part II. Description of Project
A. BASIC INFO
1. Type of excavation: (check one) New excavation ❑ Maintenance excavation
2. Purpose of excavation: (check one)oat Access Channel
13Water Intake Channel Wastewater Discharge Channel
❑ Other (specify):
3. Lake user category: (check one) rivate ❑Residential Marina
❑Commercial Marina Public
❑Other (specify):
4. Max. Excavation Area Dimensions (ft): Length JrD Width 5a
Depth
(Note: include additional area dimensions if necessary so response to #5 below equals max. area
dimensions in #4)
5. Volume of Excavated Material (TOTAL for the project):
3 70
Cubic yards
6. Type of material removed (applicant determines by field sample if practical): f C
7. Excavation Site area:O-Uo Acre (s) Disposal Site area: D • 06 Acre
(s)
8. Total Disturbed Area (including equipment staging area): 0,12— Acre (s)
9. Does a project meet the requirements of the applicable General Permit? (check one)
Yes ❑No
10. Do you claim title to the disposal area? (check one) les ONo
11. Do you claim title to the equipment staging area? (check one) 'Yes ❑No
12. Are there any water -treatment facilities within 50 feet of the proposed excavation area?
(check one) ❑Yes �No
(If Yes, specify):
13. How will the excavated material be entrapped
erosion control plan and disposal area design):_
erosion controlled? (e.g. see attached
Duke Energy Page 6 of 14 rev 2/6/17
Excavation Program

Duke Energy Excavation Permit Application Form
14. Type(s) of excavation equipment to be used: QAVA G W'9
t 8 !mq rmA e&MAtl4d r-
15. Will waters or wetlands be crossed in transporting equipment to or from the site?
(check one) ❑Yes lklo
(!f yes, explain)
16. Will return water re-enter the reservoir? (Check one) OYes ONo ON/A (If Yes, specify
points) of re-entry and show on E.rcavation Area Drawing)
17. Is there an fisting facility (e.g. pier) that access is being maintained to by conducting the
excavation? Yes ONo
(If Yes, specify the existin,$,permit number. If No, include a scaled drawing of the proposed
facility). Permit # 9/ 5
18. Total planned duration of the work (Include first equipment mobilization, excavation
through final mittlatiqn measures complete): ff
START / �-O/7 FINISH
(Mo th) (Year) (Moy�th) (Year)
Duke Energy Page 7 of 14 rev 2/61t7
Excavation Program

Duke Enerav Excavation Permit Application Form
PART II. (Continued)
B. PROTECTION / AVOIDANCE AREA DESCRIPTION
Complete the following table including all land areas within and immediately adjoining the disturbed area:
Protection/Avoidance Areas
(check all that apply)
Approx
Identification
Method *
Avoid (A) or Mitigate (M)
Acre
Field ID
Work Area DwQ. ED
a. Marshland, swamp, ponds, beneficial
aquatic vegetation or other potential wetlands
(circle all that apply)
, r
b. Buffer Zones (specify width & source
of requirement)
c. Environmental Areas as identified by
Duke Energy
d. Natural Areas as identified by Duke
Energy
�-
e. Historic properties (specify)
L Rare or threatened species (spec6)
Duke Energy Page 8 of 14 rev 2/6/17
Excavation Program

Duke Energy Excavation Permit Application Form
Protection/Avoidance Areas
(check all that apply)
Approx
Acre
a. Buried gas, water, sewer,
communications or electric lines (circle)
�l
h. Impact Minimization Zones as
identified by Duke Energy
r
L Other areas requiring specific
avoidance, protection or mitigation (spec)
Q,
Avoid (A) or Mitigate (M)
* For "Field ID" column, specify entity or person that performed the identification and how it was physically marked (e.g. Duke
Energy (John Doe)/Pink and purple -dotted tape, Corps of Eng. (John Smith)/ yellow flagging). For "Work Area Dwg ID" column,
show the symbol that is used on the drawings to identify the protection/avoidance area.
** List and attach mitigation plans
Duke Energy Page 9 of 14
Excavation Program rev «1 7

Duke Ener Excavation Permit A lication Form
C. APPLICANT'S SIGNATURES
Comments:
C�
Applicant Name (print) Eton CA-rw4t.
Lot #
Applicant Signature*�
Date 7. Z R.t?
Co -Applicant Name (print)
Lot #
Co -Applicant Signature*
Date
Co -Applicant Name (print)
Lot #
Co -Applicant Signature*
Date
Co -Applicant Name (print)
Lot #
Co -Applicant Signature*
Date
Co -Applicant Name (print)
Lot #
Co -Applicant Signature*
Date
Co -Applicant Name (print)
Lot #
Co -Applicant Signature*
Date
*Per my signature, the information provided in this application is correct to the best f
knowledge. om y
Duke Energy
Excavation Program page 10 of 14
WN 2/6/17

State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
Division of Water Resources 15A NCAC 02H .0500 —Water Quality Certification, Shoreline Stabilization
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 [15A NCAC 02H .0502(a
Owner Informati n j
Name: 0
Mailing Address: -P 0 (3 ox
Mooresvi 11-k
117
Telephone Number: LO f -'f00-/2_55 Fax Number:
E-mail Address: V -D 0 34Are- 6 riAa,.. io. yxrre.s - C-0 m
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 AUTHO
RIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: LS
Company Affiliation:
Mailing Address: 6 3 OA-,Kr'� t- /�' �►✓
Mao resJi Re.
Telephone Number: 70 V. 6(00.-5-11 t
E-mail Address: C
Person to receive the Certification Approval:
Fax Number: 6G0 X96
1 /w )i Afd �A m. Al
;.'0 i'�)rtrtq<s
II. Project Information 115A 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, 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: = e -dc fA Nearest Town: m D 0,r'csV; (i C
Subdivision name or site address (include phase/lot number): -r- c. L- "ea,✓ 14-,7-7
Directions to site - please include road names and numbers, landmarks, etc.: 'fi77 A/ t v
N i,J 0 41 M4 Sart/ iU , 4-ao� b r/i-014 y /3ai /"
Latitude (in decimal degrees) 35.5 55 Longitude (decimal degrees) OO. 1314
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): rc� d +c s►
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:
f{c 110VIMAA1
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 00- (.S 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:
6,01)( 50' x ¢-,
11. Total amount of disturbance (including all clearing, backfill, 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:
4
12. Please describe the vegetation above the normal pool lake level/ Normal Water Leveand 50
feet landward to be impacted (number of trees, for instance): rrt
i5teV/feA)
Owner/Agent's Signature*
Printed Name
[15A NCAC 02H .0502(f)]
'Agent's signature is valid only if on authorization letter from the owner is provided.
11
Date
FORM: SSGP 10-2013 Page 2 of 3

Lake
(At Full Pond/Normal Water level)
-eI
k
Full Pond/ ___ 0 C". �S .
Normals eLriLW'fi r 31 1. 00 go
Shoreline
1�5� yj/ rl j 1:bid
/f ?od'eeSVi&* aS1/1
a 7
Please approximately sketch the following information on this pian (provide dimensions for each
item, such as 10 ft x 100 ft) *:
1. All proposed vegetation clearing
Z. 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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Preview
Date: Tuesday, January 27, 2015 11:19 AM
From* Ron Carroll <[e-mail]>
To: <[e-mail]> <[e-mail]>
Subject* Jen
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