20171024 Ver 1_Shoreline Stabilization_20170815

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
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 [
1. Owner Information
Name: ui
Mailing Address:
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Telephone Number:Fax Number:
E-mail Address: a� .� • )
2. Agent/ Contact Person nformation
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Person to receive the Certification Approval:
Fax Number:
II. Project Information [
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: �' - ��t�� �m�- Nearest Town:
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.:
e.
p
Latitude (in dedmaldegrees) a►�G sem'�fi LOligi�ude(dedma/degrees)7�--?7'7'
5. Describe the existing land use or condition of the site at.the time of this application
(residential, undeveloped, etc.):
6. Property size (acres): e
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how har Br ing of shoreline has been
avoided, or why it is necessary): ill a�) r�� �� 5���t 6ue,
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:
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: - )(T
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): 7kdeP
P► c-4ure b(r©vi J
Owner/Agent's Signature rrinceu irdluc
Agent's signature is valid only if an authorization letter from the owner is provided. page 2 of 3
FORM: SSGP 10-2013

Lake
{Al tFuiI Pond %Norm al A'aterLe-rei1
11 ���
y�
l=ull Fond/
Normal Water Level
Shoreline
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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: 556P 10-2013
Page 3 of 3

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