20171418 Ver 1_Shoreline Stabilization_20171102

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' state of North Carolina
..:'�,-.� •x.,, -,_$ .sr: 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 %' 1 7 1 4 1
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
I. Applicant Information [ ]
1. Owner Information
Name: '+ J 'lei
Mailing Address: -
Li y7ccIti-4-h 4 VC SCS 9�2-
Telephone Number: '7c'4 -73J' .S70 ! Fax Number:
E-mail Address: 21�� -q K e6 Y1 e.
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded her
) must be attached if the Agent has signed this application form.
Name: I -'r— avis
Company Affiliation: Ales -,J i ul
Mailing Address: Po 80x et 3
✓Jen vim✓ /V -C_ Z X303 7
Telephone Number: FaxNumber: 70Y -5f60-1'1&2-
E-mail Address: 0 /rbc- P_ )��✓�,. ter'7
Person to receive the Certification Approval: ma4L /� SIS
Ii. Project Information [ j
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: SSCP 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) /�
County: �'� �,, 6c. --Nearest Town: AI&JUr1 Corr OVep—
Subdivision name or site address (include phase/lot number):
2 74 73
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (in dedmal degrees) Longitude (dedmal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): _ Xe�,wL
6. Property size (acres):
7. Lake/ river/ ocean ad
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): =Xr�t�
re -1014.c e rit) / ru/.
9. Will work be conducted from land? 0 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: _. 01 ;2!4f �
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):
PILl
Owner Agent's Signature U
Date
Agent's signature is valid only if an authorization letter from the owner is provided
FORM: SSGP to -2013
Page 2 of 3

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La ke
(At Full Poled/ Normal Nater Level)
Full Pond/
Normal Water Level
Shoreline
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Please approximately sketch the following information on this plan (provide dimensions for each
Item, such as 10 ftx 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
I 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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