20180107 Ver 1_Shoreline Stabilization_20180123

2 0 1 80 1 07
State of North Carolina
R _____-----Department of Environment and Natural Resources
Division of Water Resources
ISA NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources 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 k!t9 L5 Q"]
1617 Mail Service Center D
Raleigh, NC 27699-1617 ,AN 2 3 201$
Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: &-qje L.ni[
Mailing Address: IH KkidsyEPrkm
1tiAan l eQA, SC, aqq a �
Telephone Number: NLi3) LI,-a-01iZ Fax Number:
E-mail Address: 4x.cno6li\eskok e CaSeN+eCS C.( -Or,,\
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.mil/Portals/59/docs/regulatory/repdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: e)c r\ 1-irnhinc
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number: (87-8) 51?(a- !9K0'3
E-mail Address: mP4i csa . rYT-K. htSC" 6
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 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: Jo,cV wy\ Nearest Town:
Subdivision name or site address (include phase/lot number): 5��1rci�dts'. Glen t i 1�e_
L,.1� ask• Wces$ • 38ip Eos-er- l..ri. _
Directions to site -please include road names and numbers, landmarks, etc.: Gr-DoA
Ci , M cn16 &64ec lane unci. home w; I I be on the r C5 h+ in I r^; l e .
Latitude (in dedmal degrees) 35.�n� Longitude (dedma/degrees)_ !: � 13�7gg
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): 7_eSti6eAA PropgL41
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property: Lclye C-16nvAle.
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): b"Apr Sca I VAk n6\056cp -din .A- W i (1
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:
Be6,3- 300 sr-
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the nor Fool lake level/ Normal Water Level and 50 feet land -ward in
A -717 -
square feet or acres:A�_t= N%korbance -• 1 ZOOsp
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): -there ace cocks,
Jree AnQs Gy\c rne4om r4*lsees
Owner/Agent's Signature' [15A NCAC 02H .0502(f)] Dat
'Agent's signature is valid only !f an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

FL
Normal r=Level
Shoreline
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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