20180352 Ver 1_Shoreline Stabilization_20180309

State of North Carolina
Department of Environment and Natural Resources/�
Division of Water urcesA
_D WWR
ID
Division of Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form 2 0 1 8 0 3 5 2
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit V
RECl�EI` ED
1617 Mail Service Center
Raleigh, NC 27699-1617 MAR 0 9 2018
C'ENR-LAND QUALITY
I. Applicant Information [15A NCAC 02H .0502(a)l STCRMWATER PERMITTING
1. Owner Information
Name: /lAk�ai I, % ori � relg �s t
Mailing Address: _4e`6 3 $
IV 1 y n ro-t. /VC 2 I'll D
Telephone Number: _%b9G3y "4fax Number:
E-mail Address:
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/regdocs-/Permits/SAMPLE AGENT AUTH_
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: 44ty —ft 2
Company Affiliation: AIA G
Mailing Address: /h 755
N,, -i,,< J Al C 2 Y1 Z
Telephone Number: ;by 9,sS CgS'Z Fax Number:
E-mail Address: IcclEry, .., d ccs•,<�►-c,c �� u.� G ,
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

etc-), dP 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: .S unV Nearest Town: ICJ J-1 &J, G Cd -
Subdivision najne or site address (include phase/lot number): ZECE &Er✓p, it
to site - please include road names and numbers, landmarks, etc.:
Latitude lin deammd�) 3 S J y 32, 3%1.ongitude (dwm)' '� �0 �Z t�Z
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): rGsr au✓%
6. Property sae (acres): & S-
7.
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion1l/as to how hardening of shoreline has been
avoided, or why it is necessary): a�sh- tzsQc �u /J i�►o
9. Will work be conducted from land? N From water?
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool IaM level/ Normal Water Level in square feet or acres:
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
wails, etc.) above the normal pool lake level/ Normal Water Level and 50 feet landward in
square teet or acres: &= / C�ZJO s ra -P
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): saw, t.r'—
Signature Printed Name Date
115A NCAC 02H .0502(61
*Agent's signature is valid only if an authoriZ *m kner fiam the owner is provirled
FORM: SSGP 10-2013
PMe2of3
ig

SAMPLE AGENT AUTHORIZATION FORM
PROPERW LEGAL DESOW ION:
LOT NO. 8' 7Z rte,, NO. PARCEL, 3n: S 71/03 Oq ,?q 72
MWU ADDRM: 764 l't k l I ► -N
Please p ft
qty Owner: ChrjP 1
PMP&ty ate:
The W'le� r8ghtened property owners of the abm noted pDp&W, do hereby auexwlze
of
Marne of mmukhv fer,
to act on my behalf and We al aftm necesmy for the pocesft, bsetarroe and acmeptance of
this Mn* or CeMftatlon and any and aN standard and spedd wmftm attached.
Ptnpert,► Owners Address Cifent that, Pvperty above):
Ov y- c. LI 0 3 f I f re r 1' u (i�MC� - M n n "A A 1 r
+ Telephone:
Wherebof otr � inh�rm MM aftr toed in this app�lon Is true and accurate to the

12. Please approximately sketch the following information on this plan and pi o-kh dbrniam !br
&Kh AhM.
a. All proposed vegetation clearing E
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
X
I Pond/ Normal Water
Shoreline
Plan View
-� C
Lake
(At Full Pond/ Normal Water Level)
R&
FORM: SSGP 02-2017 Pate 3 of 4
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r.rrr�rf�
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.�rrr..
FORM: SSGP 02-2017 Pate 3 of 4

J
Lake �
(At Full ftW N"mal WMw Level) � .1
C
Side View0 CL
LL_
a
FORM: SSGP 02-2017 Page 4 of 4

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as maK
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VWINTY NAP
not to some
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RON STAKE BY FENCE
IRON STAKE
LOT 527
CLYDE DAVIDSON
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�NPS
NOTESi
1 BOUNDARY PREDICATED ON EXISTING
NMN*31TATMN FOUND IN THE FIELD.
2 AREA COMPUTED BY comamATE CONPLITATu*L
3 PROPERTY IS NOT LOCATED Dr A FLOOD
HAZARD AREA.
4 THIS PROPERTY IS IN A CaUNTY WHMH
REGULATES THE S UJM VIDV G OF LAND.
5 THIS IS A SURVEY OF AN EXMTM PARCEL.
OF LAND.
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