20171279 Ver 1_Shoreline Stabilization_20171009

Shoreline Stabilization Application Form 2 0 1 7 1 2 7 9
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 ( ( nn M
Raleigh, NC 27699-1617
OCT 0 n 2017
• Applicant Information [1L5A NCAC 02!`0501 a
1. Owner Information DEQ- ATER RESOUR
401 &BUFFER PERMIT
Name: � j"_ a 1iL(_c_2
Mailing Address: L13Lo S , lv* rSAA T4 -y, Ln
M N-1.1117 Jr
Telephone Number: (}g_ L�S�-t_ Q�ya Fax Number:
E-mail Address: oACA" (Xn(_Qk"Q,� a .:I• rf,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.rriil/.Pc)rta)sZ52 �ocs re ulatory/regdocs/Permits/SAMPL
E AGENT AUTHORIZATION FORM.pol) must be attached if the Agent has signed
this application form.
Name: v a"Aon wg 's
Company Affiliation: �wnQ�r
Mailing Address:
. S -C - ,24"1 Lo
1

Telephone Number: fe3 ,r31-Ffbll. Fax Number: S03-"I-
�;'1aK5
E-mail Address: r-rA ,,S 3!; eo.r-hL;n. _,ALA
Person to receive the Certification Approval:�y soh
• Project Information [15A NCAC 02H .0502(a) & (b)l
• 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.
• 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 construction access corridors.
You may use the diagram provided at the end of this application form.
• Attach a photograph of the shoreline/ buffer proposed to be stabilized.
(Include a scale of some sort- a yard stick, shovel handle, etc.)
• Location of the property (where work is to be conducted)
County: C- mr.'d on Nearest Town: ]k1nW'A'4
Subdivision name or site address (include phase/lot number):
Gk-- Imo, elr►�an,�-�.N-t. a-go�l2 ,
Directions to site - please include road names and numbers, landmarks, etc.:
_iirn EIRW4- 004- &C l%k ca cal e_n10WAA&ASeu �el No _ REQ,1
n lw{ vu v�inn will .. AQ1A dowau s o A
�?aM+l- Dn ZI tfl�r�?on i�lnle. Z3lvice • 1 44QA 4,,kL 144 -on 44 � Lc.►+ %
C4. ; loos 1 ui t 6g. Qe mA a� r,,dG" "
Latitude (in decimal degrees) 3-1;. /53970 Longitude (decimal degrees)
-V • 0a-15"
• Describe the existing land use or condition of the site at the time of this
application (residential, undeveloped, etc.): r¢s,c&A t e
• Property size (acres): .37
• Lake/ river/ ocean adjacent to property: LAk - W j ISM_
2

• Describe proposed work (include discussion as to how hardening of shoreline
has been avoided, or why it is necessary): Loi' �w At
149(s a, k _S, oy os .5 IA tis y-7, eros ► aYL _L a ke— Acs neo t� c Cc9IUJ
Gl. .9 � .S`Gl.c7i �� 2G��•
• Will work be conducted from land? js.,,•k From water?
• 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: r'r��scf-t, - / `%�/og x_ //x 3 ;Ie10
to " /.?/(e-
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: ,2o72 U.F_I, rd jam/�/g
12! Please describe the vegetation above 6e normal pool lake level/ Normal
Water Level and 50 feet landward to be impacted (number of trees, for
instance): ? frce_.5 : 3I� �y �o �rcGS
5&rci -t"fint GK'r CIJOKt A0 / A
D( e -f too/
Owner/Agent's Signature' [15A NCAC 02H .05O�ZLll Date
`Agent's signature is valid only if an authorization letter from the owner is provided.
3

I
home Insert Design barons SNde Snor, P.me.1 `: laseaMbe
J Layout -
J Reset
Dastt Item _
Slide - J Dtlett
Full Pond/
Normal Water Level
7 M 7 � i
Shoreline
Lake
(At Full Pond'/ Normal water Level)
Stde3 :1a 'CMIEe Theme' -------..- -- — --
Please approximately sketch the following information on this plan (provide
dimensions for each item, such os 10 ftx 100 ft)*:
• All proposed vegetation clearing
• Location of rip rap or fill to be placed above the Full Pond/ formal Water Level
elevation
• Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level
elevation
• Location of any proposed structures such as buildings, retaining walls, docks, etc.
• Location of any excavation or dredging below the Full Pond/ Normal Water Level
elevation
El

• Location of construction access corridors

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID: IK7 3olr6
STREET ADDRESS: _ �oSo? fieQ le ldS ( _
/S,,Im m ---f �C 2 o/2
Please print:
Property Owner: o 4 �'V
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
am I I ( C 11� ctcUSsnS r "V%�. _c?�Sf%fLf
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
Telephone:?yf-`�l0 7- P.Z Y;2
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
ill, Wl/�
Auth'z Signiuth-oordzed Signature
7-zg
Date: L Date: /O- 5--17

THIS IS TO CERTIFY THAT ON THE 17TH DAY OF JULY 2016 AN ACTUAL SURVEY WAS MADE
UNDER MY SUPERVISION OF THE PROPERTY SHOWN ON THIS PLAT, AND THAT THE BOUNDARY LINES AND THE
IMPROVEMENTS, IF ANY, ARE AS SHOWN HEREON.
NOTES: /�/},
t. PID: 18930156 I `
2. MAP RECORDED AT MAP BOOK: 67 PG:87 JUS N MCKEOWN, PLS L-4739
DEED RECORDED Al DB:4103 PG:2001
3. AREA COMPUTED BY COORDINATE METHOD_
4. THIS PROPERTY MAY BE SUBJECT TO ADDITIONAL RECORDED OR UNRECORDED
EASEMENTS, RIGHTS-OF-WAY, OR RESTRICTIVE COVENANTS, OTHER THAN SHOWN.
5. THE SUBJECT PROPERTY IS LOCATED IN A SPECIAL FLOOD HAZARD AREA AS SHOWN
ON MAPS PREPARED BY THE F.E.M.A. AND FEDERAL INSURANCE ADMINISTRATION. (AS
SHOWN)
6. SETBACKS SHOWN ARE PER PLAT.
1111h,—dow � —LAKE WYLIE—
NO2 54aacPW N10_O��g82w
.91
EIR d
10.00'. `
_
\ 11a
50' REARYARO
LOT 222
MB: 67 PG: 87
0)
N
16,189 Sq Fti
\ t \\
0.37 Ac.
o�
<
`
I
P
\\
30' SETBACK
1
LOT 221
MB:67 PG:87
LEGEND,
EIR = EXISTING IRON REBAR
EIP m EXISTING IRON PIPE
R/W RIGHT OF WAY
CP - CALCULATED PONT
TELE PEO — TELECOMMUNICATIONS PEDESTAL
PS -POWER BOX
MB =MAP BOOK
PG = PAGE
S.P.B. - SEWER PRESSURE BOX
S.C.V.-SEWER CUTOFF VALVE
CB = CATCH BASIN
LP = LIGHT POLE
SCALE iii
ON POINT SUAVL+YtNG, mix
2110 SfAT!ON QOM
MALWVUIn NC 28103
omJ21'2500
I.IMSH NO: M16
\ TP 1��t�� S.P.B.
8O LID �:
PBO CN
-64 9
\ R,4p�0 0
L=75 70
S.C.4
1
;HEADLANDS CO
(40' PUBLIC R/W)
IR 0
0.00'
I
f
�L�SII.Yf
99I� „BeTJ,�
FEMA FLOODLINE
(PER FEMA FIRM PANEL)
LOT 223
MB:67 PG:87
A PHYSICAL SURVEY
a
##6052 HEADLANDS COURT
LarmXffMB. =P0W=SuMXv=Wraz
SOMPOSr18110W15M1l►• GAMM00.l>b!'IBCAVOUKA
VICINITY MAP
NOT TO SCALE
SITE /
0"" BY:.K,'M FlEWD K ST.J .ED
LDD: 6052HEAO COGO: 6052HEAD

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