20171406 Ver 1_Shoreline Stabilization_20171101

/J State of North Carolina
I(� Department of Environment and Natural Resources
po) Division of Water Resources
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:
Division of Water Resources
401 & Buffer Permitting Unit r
1617 Mail Service Center 2 0 j 7 1 4 0 6 L
Raleigh, NC 27699-1617 ENOV1201t
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: `) d�FF � C'1 S. L� � $ IG�nJ�� L_uy �• C���1�-a�l��
Mailing Address: 1 y Loc �►M H �2i ��
--r/ c A(- i/c- l-,Qg' F L 33`1+ Sr
Telephone Number: 9aY-SKo_19cC Fax Number: ,jc&; 0-
E -mail Address: , c a r 61 1 v e. c om
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 ha signed this application form.
Name: ,?&B�
Company Affiliation:: d�
Mailing Address: / �y. ,0O Y-- !�
/5--z'0'/Vr P/Le _;_7 Zve Z a? 7 34
Telephone Number:FaxNumber:
E-mail Address:
po-/S0r� �6' Cly 0.D% cam
Person to receive the Certification Approval:
I1. 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

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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:`1/�1'� Ste✓ Nearest Town:
/v�.
Subdivision name or site address (include phase&t number):
/ P_r_ %� 4-IJ-S/T7z_- y�— Seng
Directions to site - please include road names and numbers, landmarks, etc.:
RlArl- ,/ 1, �2 e6'5::7-
Latitude
_,F`TLatitude (in decimal degrees) Jr,Longitude (decimal degrees) ::�-Z
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):.3i/�,,vTi.�–,�},�,e
6. Property size (acres): / ✓h- 7-
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline ha6 been
avoided, or why it is necessary):a���'7'� r'rr�'r Srr'd2r���
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 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: "00 Qu -
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): SDS 9-
/Agent's Signature* 115A NCAC 02H .0502(f)1 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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