20171128 Ver 1_Shoreline Stabilization_20170906

L
State of North Carolina
DW
Department of Environment and Natural Resources
R 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
Four copies of the application (including attachments) and the application fee should be sent to:
Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699-1650 1 7 1 1 2
I. Applicant Information [15A NCAC 02H .0502(a)1
1. Own
Nam
Maili
Telephone Number�_AbA-1,1A`1A, 1:4, Fax Number:
E-mail Address: Q��r� _...�or�r,c-, C CZk'4Q�� paSon��. car
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.armv.mil/Portals/59 docs re ulatory/reedocs/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: �fJ��'�� ��r, _ Fax Number:
E-mail Address:
Person to receive thi
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 cond cted)
County: �q-�-�-or Nearest Town:
Subdivision me or site address (include phase/lot number) \, �5
Directions to site - please include road names and numbers, landmarks, etc._'1;C-V_P_
PI&`- Oro
5. Describe the existing land us or condition of the site at the time of this application
(residential, undeveloped, etc.):
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as t how hardening of shoreline has been
avoided, or why it is necessary): _ 0,_\Q �ro
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:
1 -q _ oma..• �_--►
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Wa&er Level and 50 feet land -ward in
square feet or acres:
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):
I
IZ&_ \'?S -\_�
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 10-2013
Page 2 of 3

t
F
Norm
c
Lake
(At Full Pond/ Normal Water Level)
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
6. Location of construction access corridors
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FORM: SSGP 10-2013
Page 3 of 3
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8/23/2017
Go gle Maps 815 Bell Post Rd
815 Bell Post Rd - Google Maps
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Map data ©2017 Google United States 100 ft I I
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Belmont, NC 28012
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