20171261 Ver 1_Shoreline Stabilization_20171004

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
00M 0 `� J2C�S 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: L U "1 ( 1 2 6 1
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center E&BUFFER
VEC
Raleigh, NC 27699-1617
42017
I. Applicant Information [15A NCAC 02H .0502(a)]
RESOURCI
1. Owner Information ' /� PERMITTI
Name: a c�,\4)
Mailing Address:i/ 8 <._'Me-
3 Z y
Telephone Number: 4-0 4/3,_,14-73 60 Fax Number:
E-mail Address: !-E 2 e y . C,-/44
2.
, f/4-
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 AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: ©� /%�/ ���/� -S' �tu!X _C-0 ?-S
Company Affiliation:
Mailing Address:
o x- �©
C76
Telephone Number: &?, ZZG Z6417 Fax Number: -924" - 75`3 - 6 2 60
E-mail Address:�O�,v � 6 0 —` �" �-C' co'�^
Person to receive the Certification Approval: /�O%rf ,/��i" i�� D *-�
II. 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 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.e/s •,- Nearest Town: e-a/� i�•-�
Subdivisionname or site address (include phase/lot number): Z g 6f�
Directions to site -please include road names and numbers, landmarks, etc.: OM
/QiIJ %a /VD&,ql VC -f -M^,) 0.0 4L`:`7_ Tb /�E%✓tiL y
r
Latitude (in decimal degrees) 1702S-'?— Longitude(decimal degrees) —��� i �`S
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): 1101415, .S I';7:r-,
6. Property size (acres): 1 • D
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 5- ams+'os rte%�s T+�c•v r'G g e�
�-jJd Sls�'rGiL-�-T��+1i GC�Nn�Ai ,Ei � ,�-✓D�i)�iJ
9. Will work be conducted fromland?❑ From water?[X
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, S C�, ASC Oc,x_) %%v LL /moo o,L-
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: -6 ;�, 6 S a ( �e-gc v
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):
%�f iCS �� ,�,6 G`'G w<T1f` `1,,�r�,7v,n
TXIf� 74,-- oZ-- j,4/� &, pfdo'o
4 Ll
Owner/Agent's Signature' [115A NCAC 02H .
8Zz /7/ �
Date
-Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

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9/29/2017
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