20180341 Ver 1_Shoreline Stabilization_20180307

State of North Carolina
4a ,D' attment of Environment and Natural Resources
-Z EZ, Division of Water Resources
Water Resources 15A NCAC 2H 05Wf _-Vater Quality Certification, Shoreline Stabilization
ENVIRONMENTAL QUALITY FORM: SSGP 02-2017
Shoreline Stabilization Application Form 2 0 1 8 0 3 4
Three copies of the application (including attachments) and the application fee should be sent to:
If sending via US Postal Service If sending via delivery service (UPS, FedEx, etc.)
Karen Higgins Karen Higgins
DWR-401 & Buffer Permitting Branch DWR-401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street D f� @ �n
Raleigh, NC 27699-1617 Raleigh, NC 27604 L5 v D
A. Applicant Information [15A NCAC 02H .0502(a)] MAR 720718
1. Owner Information " 1
Name: ! t kAo 0'' - l.C�� A J� a e�� FER PFR ..�,t..S
Mailing Address: CC►&^0vx Oi-e w S;pc u-- &�W v\ 4ib �rti�
c.� IIA3�2 ?-'a4 Hr\r�Ovr SLa . , V�ts�S.ae1
Telephone Number: Fax Number:
E-mail Address: Q.CQSt�- ec,earc"
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter must be attached if the Agent has
signed this application form. (A form can be downloaded here:
httD://www.saw.usace.armv.mil/Portals/59/docs/regulatory/reedocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name: 'Z'4 --R S_ ` tL
Company Affiliation: kA_&f_'�0 0 y r
Mailing Address: N�A!J kA&( -`60 0l; �-A_. .
Telephone Number:Fax Number: —
E-mail Address: e CO)- � 'V'_Ck, C_ow�
B. 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, buildings, retaining walls, docks, impervious surfaces, 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.
FORM: SSGP 02-2017 Page 1 of 3

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: Nearest Town:
Lake/ river/ ocean adjacent to property:
Property size (acres):
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (in decimal degrees)
Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
7. Will work be conducted from land? ❑ From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level/ Normal Water Level and 50 feet
land -ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
Temporary impacts (temporary clearing, construction corridor) in square feet:
10. 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):
11. Signature
Owner/Agent's Signature* [15A NCAC 02H .0502(f)] Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 of 4

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: ��� ���� NearestiTown: 1` oofeS�%•1`
Lake/ river/ ocean adjacent to property:
Property size (acres): ¢ ,A, L� d j aCTeS
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.: ' r \,0_
C
t&4- 4J;a,t_._I
Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
.(residential, undeveloped, etc.): t tnfk C0A&0AQI& 0.d'eb—,yy\A_\N_ k OUP A
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): N rreGk 9k0MV me, IG:fb5�,o - f-e-o�.ce, • 0.��
t, r&O akot� SkoretrnP_ . a&k soL.4 bac l- Im R -Y zs ina Ili' areoa , re,&o,
a-� (eP_flocej 10 ae(,& tree`s , a6a_ vel !;DA
7. Will work be conducted from land? (R From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permaneimpacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
. � U_ x ( q1 +- iZS =*L1b 1 = (n 499 qa,,, 4
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
Temporary impacts (temporary clearing, construction corridor) in square feet:
h�6�_
10. 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): ko Are -RS 0 re � eaa
X\) -t jt _,ros,on fe_kov,, av`ci reAcp, k'ees aid ve4-9A-oiah
V,kPIL \J
11. Signature
Z �
Owner/Agent's Signature L1 A N AC 02H .0502(f) Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 of 4

12. Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
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
La ke
(At Full Pond/ Normal Water Level)
Full Pond/ Normal water Level
Shoreline 1
Plan View
Full Pond/ Normal Water Level
'Ircre'°ne — r'
2 ft.x 150 ft. i
additional clearing
' H necessary
Plan View
Lake
(At Full Pond/ Normal Water Leeel(
Existing Dock
/ 30ft.7ft
3 ft■150ft
Below full pond/ N WL
afta150ft
Above full pond/ NWL
� dead �Qp<
FORM: SSGP 02-2017 Page 3 of 4

f,
Lake CU .
(At Ful I Pond/ Normal Water Level)
C
crti
E2L
d 0
Ln
C-
Side View
U-
10 ft. bank
MEM
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
f necessary
Existing bank
a���
160,
FORM: SSGP 02-2017 Page 4 of 4

1 >
Lak '
{At Ful I Pond/ No Water Leve _
o
0
,.. P
Side View
0-
U_
10 ft. bank
Side Vi
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
if necessary
Existing bank
FORM: SSGP 02-2017 Page 4 of 4

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 2 PLAN NO. PARCEL ID:
STREET ADDRESS:i��� �a
V31 -&V S�
Please print:
Property Owner:
Property Owner:
(-�oJr
\r 6i r
The u dersigned, registered property owners of the above noted property, do hereby authorize j
of 1 1NLY0 r
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
rlpo�ft
Telephone:
LO I �T
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized ignafture Authorized Signature
Date: Z I Date:

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Lake Nomran Really Inc Mad - Harbour Causeway Project
LAKE NORMAN
REALTY, INC.
REM [STATE
:D"Y'"'ES
TME W091D-
Harbour Causeway Project
Terese O'Dell <[e-mail]>
To: Terese O'Dell <[e-mail]>
Causeway repair
91' of rip rap from Kingery's side to 1 st tree
Beach 10' of sand to this tree which will be removed
Beach to run off
125' and wrap around into run off about 15 additional feet
Replant with shrubs and button bush 80'
Between edge of rip rap and drainage ditch
2/15118,1222 PM
Thu, Feb 15, 2018 at 12:10 PM
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