20180448 Ver 1_Shoreline Stabilization_20180326

State of North Carolina
2 0 1 8 0 4 4 8 Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water
Cel horetine Stabilization
AM: SSGP 02-2017
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the : oplication 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
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information 115A NCAC 02H ,0502;
1. Owner Information
Name: ` J
Mailing Address: 3 ,-r
D Q- ATER RE S
Telephone Number: i�0f li "7 2 Fax Number: E I�
E-mail Address:
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:
Clap./Jvvwvv.ya. t! dt M Y-Mlijrortaisisyidocs,/regUidtorYiieguocs/Permits/SAMPLE AGENT AUTHORIZ
AT±nns FORM.pdi )
Name: S trs a G'C{r .,
Company Affiliation: �h,1S ,••��t�, ,,��'�,;,j;,,�
Mailing Address: I>l x? c>x I %�
^ e
Telephone Number:52.. . F. < <r� Fax Number:
E-mail Address: �, yu, , f; i el
B. Project Information [? 5A 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: -A, , r, 4 L, ty Nearest Town: i) c ( Y) -'n
Lake/ river/ ocean adjacent to property: L a d4"
Property size (acres): _ , y- It
Subdivision name or site address (include phase/lot number): G k- y 4' 1--
Directions to site -please include road names and numbers, landmarks, etc.:
Latitude (in decimal degrees)_ Z Longitude (decimal degrees)_
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): s, fav„ j; 4 j �/`� �d 7'-,,-/
i/
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): 21,,.,,/ -t„ < y
7. Will work be conducted from land? Q Yye ' From water? 11
8. Total amount of impacts below the normal pool lake level/ Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining etc.) in square feet:
Temporary impacts in square feet.
9. Total amount of impacts above the normal pool lake level / Normal Water Level and SO feet
land -ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
�* c ' L /
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): r.C' .c{, e
nit5�/ {1 r i 4
Y '7;'
l i � , r.v.i/ .� %�.' ci a
11. Signature
Owner/Agent's Signature' (';A NCAC 02H .0502(P' 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
Full Pond/ N-xrnall water Level
Shoreline
Plan View
Full Pond/ Normal Water
Shoreline r
N. �W
a1laana :kan:,
' ana:abir4
Lake
[V fell P..ndj Normal Water Lei�l)
IV 1
1570,
-, ". ' "A-
utake-
�,,.,ai,,
fxiszirg Dock
. lij a
SSaa W P.W aurt
a a a1f.Q
SKr++•9 Ca,�/ MtL
Plan View
FORM: SSGP 02-2017 Page 3 of 4

0
La ke
fAt Full Pond/ Normal Watt
Side View
80& w
u a-k�*r
10 ft. bank
*�ght
Side View
3 ft. below ftil pond waLer eK-i 4 ft. atxwtt td para wat-r kvd ` n' ti r cir araig
' it n` ces<ary
,a -
FORM: SSGP 02-2017 Page 4 of 4

ciiAMI LE RG A: ;' ,� .'TKR Z,�1C'�C": FORM!
:gra' ^es.wotic^,
a,Z46 t0:
1-01 ►vo. fir) PSa.^. ;�:. ! , ap;'� e
wee—Address (if ePP0C?I'7*- 1:
^+apes Nacre ;print}: _C }mar L •3 �a Ge Y 4 3CLn'e-t- rQ r'
propefty Owner's M- dress (ii different than, Ute ab--ve),' _,1 0o Ng, —,& ev i"
�wrier Signature:
The atim« registered property owners of the above property, do hereby authorize
of
Agent Name
Agent Company Name (if applicable)
to acct on my behalf and take all actions necessary for the application, processing, issuance and .
acceptance of this permit, cert Acatior. or authorization including all standard and special conditions
attached.
i hereby certify that the above information submitted on this form and application is true and accurate
to tate tress of my knowledge.
Authorized Agent Name / Company.
A 41horized Agent Signature:
Date:

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