20171414 Ver 1_Shoreline Stabilization_20171102

2 1 7 1 4 1 4
Duke Enew_Excavation Permit Application Form
FOR DUKE ENERGY USE ONLY Air7
Duke File Na I
Application Fee $ Security Deposit S Check # Date Re cv'd Initials
Date of Duke Energy Lake Services, applicant and/or contractor on-site inspections Date Initials
Date Final Protection/Avoidance Area Markings Field - Verified Initials
Approved to Start Work By * : Date
(Pilar) (sign)
Date Completion Required Date of Any Approved Extension Initials
Dube Passed Closcout knpaction* Initials
Any Stop Work Orders or SMG Violations*? (check one) ❑Yes ONo (!f Yes, exp/pin in PART V)
Date Deposit Refunded Initials Date Permit Database Updated Initials
* Forward copy of approved application (all pages, plus any attachments that Duke Energy changed) back to applicant
with Approval Letter and highlight any changes. File copies of Approval and Close-out Checklists and any Stop Work
Orders with application.
D
art t. AppticaIIt l tormatton {r'iirase Print)
Name � -� Telephone kq- 9 9 l..p �- �g q �
Email address: ncv�f-o Ca M-�o\ , Guru
Lake Address
Contractor Company ti
Contractor Contact Person
Mailing Address ff dzfferent)
,iI- �b
Y't � C,t-�"-� �(
Contractor Email Address: C1✓CLMWI AL
LA1KE LUT iNFQkMA l0N
R
Telephone
;l no��lu�c�,r►�+. n-ef-
Lake jj .� ounty 1-1 r) city Ver State s Tax Map No.
SubdivisionWal Kd U 0'02 -
Lot / Section No. Lot Size __ Acres
Duke Energy Page 4 of 14 rev 2/6/17
Excavation Program

Duke Energy Excavation Permit Annlication Form
Are there any Co -Applicants*? (check one) ❑Yes ❑No (If Yes, include names, addresses or
lot numbers, phoiae ntunbers,fol sizes in PART V — ADDITIONAL INFORMATION)
* Co -Applicants tKist when the proposed work .is;being done wader a single application, will be
performed by a single contractor as one continuous project, and is done to benefit multiple
owners / lease holders of Project -front properties within a single development. The check for the
application filing fee and security deposit should be from the party shown as Applicant and not
several checks from the Applicant and Co -Applicants.
Do not continue the application until an on-site c
between
Duke Energy Lake Representative and the applicantnt and/or the excavation wtion has been cont actor. a
NOTE: Initializing this portion of the application by a Lake Representative in no way
constitutes approval or eminent approval of the excavation or any other lake use permitting
activity.
Date Of on-site inspection Z
Initials (Duke Energy)
(applicant/contractor)
Duke Energy Page 5 of 14
Excavation Program rev _�6�t7

Duke Enersv Excavation Permit AyOicatton Form
Fart fl. &.Scrip€ on Of Tale -CE
A. BASIC NFQ
1. Type of excavation: (Check one)
2 Purpose of excavation: (check one)
❑ Water Intake Channel
❑ Other (specify):
Zew excavation [I Maintenance excavation-
10Boat Access Channel
❑ Wastewater Discharge Channel
3. Lake user category: (check one) d/private. ❑Residerttial Marina
❑Commercial Marina ❑Public
❑Other (specify):
4. Max. Excavation Area Dimensions (ft): Length 721) Width L40
Depth 5
(Note: include additional area dimensions if necessary so response to #S below equals max. area
dintensiam in ##4)
5. Volume of 'Excavated _Material f 70T4L e 4e p ); 72Z Cubic yard
6r'Typ a of material removed (applicant determines by field sample if practical): 15(wd(.u'lu
7. Excavation Site area: Q - ` A (s) Disposal Site area:
(s) I_ Awe
8. Total Disturbed Area (including equipment staging area): P. O Acre (s)
9. Does a project meet the requirements of the applicable General Permit? (check one)
Yes ❑No
10. Do you claim title to the disposal area? (check one)Yes ONo
11. Do you claim title to the equipment staging area? (check one) 1'es ❑No
12. Are there any watetreatment facilities within 50 feet of the proposed excavation area?
(check one) ❑Yes No
(If Yes, specify):
13. How will the excavated !Material be entrappO and the erosion
plan
area design
(q g. see attached
Duke Energy Page 6 of 14 rev 2!6/17
Excavation Program

Duke Enemy Excavation Permit AMication Form
15. Will waters or wetlands be crossed in transporting equipment to or from the site?
(check one) Oyes P&O
WYes, explain)
16. Will return water re-enter the reservoir? (Check one) OYeso ON/A (If Yes, sped
points) of re-entry and show on Excavation Area Drawing) fw_
17. Is there anflze�existin
isting facility (e.g. Pier) that access its being maintaaxtecl to day canc�x�c�king t" e
excavation? es ONo
(If Yes, specify permit number. If No, include a scaled drawing of the proposed
facility). Permit #
18• Tom }Manned duration -of the work (Include first equipment mobilization, :excavation
through final mitigation measures complete):
(Month) (Year) (Month) (Year)
Duke Energy Page 7 of 14 rev 2/6117
Excavation Program

Duke Epergy Excavglion Permit A ficc bion Form
PART U. (Continued)
B. P&OTECTION / AYQIDANCE AREA, iEaCRIPTION
Complete.the following table including all lend areas within and immediately adjoining the disturbed area:
Potection/Avoida`uge Areas AoD Ide ific'tion NOW, * Avoid 1►itiQate (M)
(check all that apply) cre eld lD Work AreD
_ _a. Marshland, swamp; ponds, beneficial
aquatic vegetation or other potential wetlan&- N Y
(circle all that apply) Y
--7b. Buffer Zones (speq y width & source t Rn� it
ofrequirenient) vW ,.,j
"C�+O(
T - 0 �A4 tUA/W-
_ �c. Environmental Arxsas as identified by "
eDuk'Energy
Td. Natural Areas as identified by Duke
Enemy N l
-__.e. Historic properties (sped)
f. Rare or threatened species (spec)
r V�
Duke Energy Page 8 of 14
Exca_tation Program rry 2/6/17

kike Energy Excav ition Permit Aapli-ration Form
Protection/Avoi'aace Areas
(check all that apply)
Anfrox
Idendfication
Met _
Avoid ,R) or Mitigate (M)
Field ID
Work Are't-Dwt ID
�___ 9. Buried gas, water, sewer,
communications or electric Tines (circle)
1vv
_ _h, impact Minimi,` ition Zones as
id= ified by Duke Energy
�
._
_ i. Other areas regi]+ring specific
avoidance, protection or miigation (spec)
For "Field ID" column, specify entity or person that pert, `trued the identification and how it was physically marked (e.g. Duke
Eng rgy (John Doe)/PijA and purple-dotte+_A tape, Corps of Enl�, (John Smith)/ yell,,,)w flagging). For `"Work Area Dwg Tlj" column,
show the symbol that is used on the draw ags to identify the l-rotection/avoidance, area.
** List and attach mi' ?.-igation plans
D ,ke Energy Page 9 of 14 rev 2/6117
E? ,.:avation Program

Duke Eneray Excavation Permit Application Form
C. APPLICANT'S SIGNATURES
Comments: si kl(Ac011i t IV 'TIM.St 140
/, ( fit
� i
r
Applicant Name (print) ��Q�� 1�r of ncL, Lot #
Applicant Signature* WL -4U , DjJ* Date A- Dl- I`" I
Co -Applicant Name (print)
Lot #
Co -Applicant Signature*
Date
Co -Applicant Name (print)
Lot #
Co -Applicant Signature*
Date
Co -Applicant Name (print)
Lot #
Co -Applicant Signature*
Date
Co -Applicant Name (print)
Lot #
Co -Applicant Signature*
Date
Co-Appffemt Ntme (print)
Lot #
Co -Applicant Signature*
Date
*Per my signature, the information provided in this application is correct to the best of my
knowledge.
hilre'Fner$Y Piege 3ih of 1k44' rev 1/6/17
Excavation Program

CATAWBA RMPA TAN BU FFER NUTIFIEAT ION FORM
Ower. "1 D, r q rn ct+
Print
Contractor/agent:
Signature
Print Signature
The approval is for the purpose and design described in your appticaiion. impacts not indicated in the
application is a-&Iation of the Buffer Rule. Site � ciflc work should be provided in the application. f 15A
NCAC 02H.0506 and 15A NCAC 02B .0243(8)}
Trees are not allowed to be removed from 7.one l of the Buffer (within 30 ft of the full pond elevation), unless
approved. Exception, those trees that are severely umdcrmin ed along the immcdiate shorcline can be removed.
Pini mat shaping and slopimg ai mg the imvned-aw suiosel m.:,` al OWCL . !:1 SA NCAC l?3'3 . _'Qutiti)a
Benching, grading in the buffer is not allowed. Excessive disturbance of ground cover. [I 5A NCAC 02B .0243
(6)]
Beaches, impervious patios, impervious walkways, etc. are not allowed in the buffer unless specifically
approved by the Division. Tliere are limitation on size for decks. f I5A NCAC 02B.0243(4) and (6)j
Work to be coaducted from land must indicate an access and indicate any trees that are to be removed. Ihe
work corridor should be described. The approved access corridto shall be restorers. Staging, spoil, conbiruction
material must be outside the buffer. [15ANCAC 021I.0502 and 15ANCAC 02B.0243 (4),(6). (8)]
Stormwater cannot be piped or channeled for direct. discharge to the lake. All constructed stormwater
&scliarges mug be at the natural elevwlon and discharged prior to catering the buffer directed as diflim or
sheet ��aw at �Soir-eri2$!t't' i�LL3ir.'S tC! #�?�ii'. 1 SA QFC 1 f =H' T$?(5i+ 16)4
Acknowledgement afNotificartion
1, �1 `)fir` l� rrKkP , hereby sure that I have been informed of the Catawba
Riparian Ruffer Rule. Any work conducted in the buffer, not specifically stated in the application and approved
by the Division of Water Resources (D WR), is a violation and subject to enforcement. Due diligence will be
taken such that the construction %%-ill be built within substantial compliance and intent of the 401 NA'ater Quality
1.4:71.t11Q-1t'1 •'2i� >Tej-Pt, ','v '*:??:'?t Fes?='';t_; s,icc:; fic�-Jvi44(, urrti U -67C 5.1't?PCrtMg Mat
Signature (owner).

State of North Carolina
Department of Environment and Natural Resources
DW.K Dh►islon of Water Resources
Division of VVner Resources "-'_AC Or;' '0500 —Water .Qua"tli Certiru:ation, Shoreline Stabilization
FORM: SSCP 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
I. Applicant Information [15A NCAC 02H .0502(x)]
1. Owner
Name:
Telephone Number:
E-mail Address..
2. Agent/ Contact Person Information
Number:
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http://www.saw.usace.army mil/Portals/59/docs/reeulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.0 ) must be attached if the Agent has signed this application form.
Name: CM., �V t 3 QPIIN0 01 I&V &&At-�
Telephone Number: '>1[( Fax/ Number:.
E-mail Address: A
Person to receive the Certification Approval: Uk4 E 61.
Il. Project Information [15A NCAC 02H .0502(a) & (b)]
1. Attach a viclinity ma I's a. } :.t n .. ", rye, -x. _> .� ,, as
>�.. �,�'V%l a.EY +i r eil teiG luLgClVr! Ve t is F::tl dG i�% 9P{%IL[1
respect to local landmarks such as towns, rivers, and roads.
2. Provide a detailed site p-lan showing property boundaries and proposed locations of
vegetation clearing, structures (buildings, retaining walls, docks, impervious surfaces,
FORM: SSGP 10-2013 Page 1 of 4

construction access corridors. You may use the diagram provided at the end of this
application form.
I 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: LJ 04A Nearest Town: — -�
Subdivision name or site address (include phase/lot number):
1?irPrtinnc tr, sitn - n)ee inrlu:�l r-.-a
_ av��p "Ou la iic5 di immOers a--almarks, etc.:
e gilt V 4y `M�,Y � V fc)NA1
Wes
... w
Latitude (in decimal degrees) ��K575-7 Longitude (decimal degrees) &__q ! /(©
- �!10t! t ;L existing ianci use or condition of the site at the time of this application
(resontial -undeveloped, etc.): 1 ,t :,Q S MGI �
6. Property size jacres): ,q2 0 . r
7. Lake/ river/ ocean adjacent to property: �! [ tIMYt6W
8. Describe proposed work (include discussion as t? how ,hardening of shoreline has been
1 'I w V VILAA �,} �ee, 1 C— �
y V � W-
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 IP%,Aii Kinrmal Water Level in square feet or acres:
17t? v IA fly
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: U Y wy XI
12. Pease describe the vegetation above the normal pool lake level/ Normal Water Level and 50
feet landward *o'be i; pacter rs! rn tr�r cf trete r _ - !I?! r R t9 lir*
.w,.. �.
v-----'• n�icu rYpnl: va Ce
[15A NCAC Q2H .0502(f)]
•A 0 _
AYE— , siyrutwe is vuhu oniy T an autnorizotion letterfrom the owner is provided.
MMA.;.. v.., yu 4-, " Page 2 of 3
:,

LbkL-
( t FuH noru.1/NamnA "=+crier Uv -SI
Ful Pond/
Norm .
Shoreline
t
i�
PipncP a nnrovjrnatplre .4es?trh thafr 4tn%minrt infnrmntinn nn'this elan ltynwWe t'jtrneasions Miremb
iterA such as loft X 2ooft)*:
1. All proposed vegetation clearing
I Location of rip rap or fill to be placed below the Full Pond/ Normai `water Level e►evat,on
4. Location of any proposed structures such as buildings, retaining walls, docks, etc.
S. Location of any excavation or dredging below the Full Pond/ Normal Water Levr-1 el-evatior,
6. l nratinn of rnnctnlrtinn nrrocc rnrririnrc
FORM: SSCP 10-2013 Page 3 of 3

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