20180471 Ver 1_Shoreline Stabilization_20180402

State of North Carolina
Department of Environment and Natural Resources
DWR 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
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
Applicant Information [15A NCAC 02H .0502(a)l
1. Owner Information
Name: f� < < /6If Xetfe'E' *05k'"V'
Mailing Address: 6q3 Verona 18
t' ;555 nn A -11S,. pis 1.(D20S
Telephone Number: (q1'3)2217b,� G 5 Fax Number:
E-mail Address: dPhl2r►stJJa r'8�m . rom
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
httn://www.saw.usace.armv.mii/Portals/59/docs/reRulatory/reRdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: Aibar± 12CU ion
Company Affiliation: _Alru s= T►_Ur sNa
Mailing Address:
Telephone Number: 0<0 743-3304 Fax Number: aQt) '143- 330q
E-mail Address: 1J11-C6M
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: _T-eAr_kson Nearest Town: CCL;5h i ec-s
Subdivision name or site address (include phase/lot number)):
LCxk,e �n,r-es+ subcli ✓i seen n Lo +' tviL'h (
bar `l
Directions to site - please include road names and numbers, landmarks, etc.: (rosy f Gg8a in
les
-Pnrn r4eh4 on Clathocrez. 41,u e,s rzq4i a"fb y:ncde/ Ayo Sallew -4-3 e,4LatltUde (in decimal degrees) 35. 113$s52 Longitude (decimal degrees) — d3s'S 31cIoq
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Aestd en+QI
6. Property size (acres): . 6 cLr er5
7. Lake/ river/ ocean adjacent to property: La ..e(tel enrllle-
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Ig4oLkI 5 "Y cont' sea WaIll A 12rQrerw+
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:
5 yX f tin FF - 2500 fZ
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: :Z"' X 5 D a e+ = /. 600 F+- :
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): %",2
ear ese�osed roes / e e s . 5%P5 , l r In 6:5
caner/Agetn ' Signature" [15A NCAC 02H .0502(f)] Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Ft
Normz
S
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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