20171390 Ver 1_Shoreline Stabilization_20171030

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 l
1 7 1 3 9
Four copies of the application (including attachments) and the application fee should be sent to:
1
Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699-1650
Applicant Information [15A NCAC 02H .0502(a)]
Owner Information
Name: -JL--_ pe1 LLli47—f✓ AAF7,1Z11"6t2
Mailing Address: 4-4- n _D &L- ST.
P_► LUc. 2.a0��
Telephone Number: 60_�5 4Z.2 -526a Fax Number:
E-mail Address: K/`,A TP,�C 7 C I -S,0 Z0 K&
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
ORIZAThOk FORM. df) must
be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number Fax Number:
E-mail Address: �L►—� �SC`������`n\
Person to receive the Certification Approval:
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 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 conducted)
County: l �T•)_QW E5.6. Nearest Town: Et -2
4RLC_ 7FOR n
Subdivision name or site address (include phase/lot number): 67f_�i
15L.e -ISR . 50, r✓ FRA L L -L's 4-0 R o
Directions to site - please include road names and numbers, landmarks, etc.:
F,T [ � Tawa.Fzr� l�-��wro►-i T�Roty` ��r.�r�z�.ttu�,� tGl-�T D�.t, I S�,
Cwt (..��fi' �-� n.�.t o 5 ► o � � u sT � � Q� "Dr=�.n �►,l.o,
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): _Ri✓S i Oe 1._1T I NL -
6. Property size (acres): l I Z 4 -cg E 1'
7. Lake/ river/ ocean adjacent to property: Lky—e Qopk&t_, -
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is
yitis nec r l�) .' _��
9. Will work be conducted from land? From water? xf�c�
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:
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): • �o
---- /'ciS- Zo) 7
Owner/Agent's Signat re* [ 5A 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

V -q �-A P
Full Pond/
Normal Water Level
IMI
Shoreline
Lake
(At Full Pond/Normal Water Level)
IMI + IMI � .
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
FORM: SSGP 10-2013 Page 3 of 3

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