20171052 Ver 1_Shoreline Stabilization_20170818

State of North Carolina
I}(� Department of Environment and Natural Resources
1 l% 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
Three copies of the application (including attachments) and the application fee should be sent to:
If sending via US Postal Service
Karen Higgins
DWR - 401 & Buffer Permitting Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
If sending via delivery service (UPS, FedEx, etc.)
Karen Higgins
DWR - 401 & Buffer Permitting Branch
512 N. Salisbury Street
Raleigh, NC 27604
A. Applicant Information [15A NCAC 02H .0502(a)]
Owner Information 2 0 1 7 1 0 5 2
L
Name: To Incy 'r Mi C_6s= G '�P_oIliaGYSok
Mailing Address: 2-2 % >M N 1,-v b OR (L 7a:_.zc
Telephone Number
E-mail Address:
10 439 8L47 Y Fax Number:
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:
htta://www.saw.usace.armv.mil/Portals/59/docs/reRulatory/re2docs/Permits/SAMPLE AGENT AUTHOR
IZATION FORM. df)
Name: Ob(in Pc C, kre
Company Affiliation: T-- 1C. c <..-tC C aeu}p_c.. CJ S
Mailing Address: 10 S ? U i 110 j Qom_ ll ;Ied 4V'e 2,_)ea,,A
111•(_ 24l'L?
Telephone Number: 70 Y c/3 $ b6 / G Fax Number:
E-mail Address: u i / A Li d (;;) 44::6 A 'f m2e-/9n , h) E-4
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.
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.
FORM: SSGP 02-2017 Paee 1 of 3

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: MON 44,n,n„r1 _ Y Nearest Town: T
Lake/ river/ ocean adjacent to property:
Property size (acres): l f — Q, c it- t 2S
Subdivision name or site address (include phase/lot number):
Directions to sitV
lease include road n sand numbers, landmarks, etc.:
AL u 2 �z �d
Latitude (in decimal degrees)
Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): ?-c
6. Describe proposed work (include discu sion as to how hardening of shoreline has been
avoided, or why it is necessary): _:. � R e t - ,j % 4Pt b; 1 i z_e,+r %r✓
7. Will work be conducted from land? � 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 walls, etc.) in square
feet:�-
Temporary impacts in square feet:
T /ell/ -54 ACZ:4- I D'D
Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent acts (including back fill, excavation, rip rap, retaining walls, etc.) in square
im
feet. / D�c"i� f -J61 II E� �
Temporary impacts (temporary clearing, construction corridor) in square feet:
10. 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): /✓oA
1natu
611,11"_ ;?/ / //7
Owner/Agent's Signature [15A NCAC 02H .0502(f)l Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Paee 2 of 4

V,
La ke
(At Full Pond/ Normal Water Level)
Side Viewo
0-
U-
10 ft. bank
height
Side View
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
'if necessary
Existing bank
FORM: SSGP 02-2017 PaEe 4 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
La ke
(At Full Pond/ Normal Water Level)
'-/ X IS -0 Tk
Ij poNd
� � G
61
Full Pon cl� 0 1 iefr vela rD=S�Ln��
LP ��r i lie d �rCP
� a e? ! �6 b d s r' Lo
60o 0Sly �� x i s -a �-b o J� TL4 PowCJ
Sf
Plan View /2P6
FORM: SSGP 02-2017
Full Pond/ Normal Water Lev
-Ihoreone
2 ft.x 150 ft.
additional dearing
if —essary
E
Lake
(At Full Pond/ Normal Water Level) Existing Dock
/30 ft.7ft
3 ft 150 ft
Below full Pond/ NWL
� r,4hnx�150T-
_ h
Above full Pond/ NWL
Pave 3 of 4

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