20171411 Ver 1_Shoreline Stabilization_20171102

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: SSCP 10-2013
Shoreline Stabilization Application Form
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
Raleigh, NC 27699-1617
Applicant Information [
1. Owner Information
Name:
Mailing, Address:
2®171411
RECE E-
NOV -2 2017
DENR-LAND QUALITY
S T ORI'dWATER PEKiIr1 TAG
Telephone Number: 16� US 3 - 70 -1 Fax Number:
E-mail Address: ril�ll Gly a� _&M PctnL1 vtM ` �/C' r
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Person to receive the Certification Approval:
It. Project Information [ __
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)
. Nearest Town: A'lf, �7y
County. .
Subdivision name or site address (include phase/lot number):
0l0 N Z
Directions to site - please include road names and numbers, landmarks, etc.:
-16
Latitude (in dedmal degrees)__S 3 ;' 1
Lora Ude (dedmaldegrees) �b I
5. Describe the existing land use or condition of the s-Ae atthe time of this application
(residential, undeveloped, etc.):S iG�=�"¢► ��
6. Properly size (acres): 7
7. Lake/ river/ ocean adjacent to property:1
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): lfn lib
9. Will work be conducted from land? © From water? ❑
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below theyormal pool lake level/
'017 i. .- -/ %-1^
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
50 feet landward to be impacted (number of
.111
level/ Normal Water Level an
i
ince):
V
Agent's Signature
Printed Name
Agent's signature is valid only )fan authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Lake
(At Full Pone; NO.-Mai
I� 1
r
)u `
Pull Pond/
Normal Dater Level
Shoreline - y
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.
S. 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