20180499 Ver 1_More Info Received_20180514

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.YSOM Nearest Town: gty+nOrO►•
Lake/ river/ ocean adjacent to property: X! to "kA
Property size (acres): Al QL"J _
Subdivision name or site address (include phase/lot number): Th.. �e.bs�v ut
Loi 1$
Directions to site -please include road names and numbers, landmarks, etc.: iiWj�116Li{�►r
OR 9L 5_ 1t 7 Dbw ' l+&f , Rd- 1313 , +IJY" iriA+ nv►-6 7 t rtu►
Uir a.} mikes), Tv^ ktf+ ovdo p%nssberi h UPr .5 mils Ttkrn
Latitude (in decimal degrees) Longitude (decimal degrees)
Rd- (Tarr 1 mid) W c ks \bh Wil' be orn +4 10+1
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Pi. 30,4d e- V2A-ZCL_I
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): r i n r., p oh 180 � 04 Sk ric Li. --e
T
7. Will work be conducted from land? ©___ From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
i•(0 ml il.S)
Chun l
Itp of a""
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
36o n j--4-
Temporary
--Temporary impacts in square feet:
/lone
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:
-7 ZD 5s /'-'I-
Temporary impacts (temporary clearing, construction corridor) in square feet:
n 0 ri
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):/tf`S
11. Signature ^.1
r
Owner/Ag is Signature' [15A NCAC 02H .0502(f)1 Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017
* C hang cs ma.cI t'51017
Page 2 of 4

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 1$ PLAN NO. PARCEL I D: 145
STREET ADDRESS: 1 \ li E Ska��
*VL 41343
Please print:
Property Owner: 366
Property Owner:
The undersigned, registered property owners of the above noted.property, do hereby authorize
,of �01r��owi5 1.®Y'1'6�YLlIL��6H.IM�,
(Contract r / 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):
35-50 S. C. %tLvck Sir 'burl;VlakAFL @I W3
Telephone: 334• S911A• 0280
!' ,We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
9'
i,
Authorized SignatV"
Date: M&A�A` b 1 $
Authorized Signature
Date: