20171333 Ver 1_Shoreline Stabilization_20171018

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State of North Carolina
Department of Environment and Natural Resources
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 If sending via delivery service (UPS, FedEx, etc.)
Karen Higgins Karen Higgins
DWR — 401 & Buffer Permitting Branch DWR — 401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Str (5 MW(
Raleigh, NC 27699-1617 Raleigh, NC 27604
OCT 1 B 2017
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A. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information R RESOURCES
\ �+ R R�jcPER PERMITTING
Name: �i1f`j '�IC�KO�(n
Mailing Address: G44 Q,;; LA
Lsuti$ ir-li, A& 2-75,L/c/
Telephone Number: IN- YA gg9F Fax Number:
E-mail Address: eIC.kti,aY- I
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:
http://www.saw.usace.armv.mil/Portals/59/docs/regulatory/resdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
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 Page 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: Nearest Town: EVh n
Lake/ river/ ocean adjacent to property: L,3,4
Property size (acres): o
Subdivision name or site address (include phase/lot number): 73 3 5 ayc�T,c�� Dr
LCLAA vr-i . 1VC 17<20
Directions to site - please include road names and numbers, landmarks, etc.: -Cklb-
f ;v a�t +VU yak, Ar;ye tJr 'J +-Ic- a tJ4yA 0-H,'U motelStu' �LY rh c^
Latitude (in decimal degrees) Longitude (decimal degrees) v, f� 1 `
Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): fes;,t, }Zul 17 , , ��c+{;w� ow J, - �M, + NI'.J dct-l<
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): r„ r•n a� C'4%K
7. Will work be conducted from land? RI 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:
Q
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
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): Dir+ /9-u sbuk IUu,?—
kL-t -ITU-5 L—A A -v,+ Pla" C'rc
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11. Signature _—
Owner/Agent's Signature* [15A NCAC 02H .0502(f)] Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 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
Lake
(At Full Pond/ Normal Water Level)
6u.e SS
Full Pond/ Normal Water Level
Shoreline i
Plan View
FORM: SSGP 02-2017 Page 3 of 4
P.M
qtr
ft- rto'
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FORM: SSGP 02-2017 Page 3 of 4

3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
f
Existing bank
10 ft. bank
Side Vi
FORM: SSGP 02-2017
necessary
Page 4 of 4

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