20181039 Ver 1_Shoreline Stabilization_20180727

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State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 02-2017
Shoreline Stabilization Application Form
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
Raleigh, NC 27699-1617 Raleigh, NC 27604 tl
A. Applicant Information [15A NCAC 02Fi .05G2(a)]
1. Owner Information
Name: E.. &dr,
Mailing Address:
Telephone Number:
E-mail Address:
414 VFD
sr&AI ?018
�!44bin
7q 11-6 Fax Number:
KeAJ, 5-fe L�J'j't.'d_sJrrt'A-* A;(�-1
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:
http://www.saw.usace.army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
B. Project Information [15A NCAC 02H .0502(a) & (L ]
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)
1
County: �Sc ' /' Nearest Town: 0 �' 670—
Lake/ river/ ocean adjacent to property: 44 (f,
Property size (acres):
Subdivision nanyo or site address (include phase/lot number): 6
Directions to site - please include road
Latitude (in decimal degreesl D�1, `l� Longitude (decimal degrees) �CJ> /0y.�slU
S. Describe the existing land use or condition of the sit th ti of this application
(residential, undeveloped, etc.):
6. Describe proposed work (include discussion as to how
or why it is
IfI/x 'r) C,
7. Will work be conducted from land? [!
of shoreli� has been
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�sgp*e feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including back
retaining walls, etc.) in square feet:
Temporary impacts (temporary cleat j% 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
11. Signat rVSJUJ V, 4�Ao"
dILz- (� L17 —�:) -� e) K' C- I,-
Owner/Agent's Signature* [15A NCAC 02H .0502(f)] Date
Agent's signature is valid only if on 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/ Normal Water Level
Shoreline
Plan View
Lake
(At Full Pond/ Normal Water Level)
Alaa �v6ta,� A4
11/2
Lake
i:a r.a w—V Fairer t-4 Existing Dock
3E irx7k
ftx ISO It
8,1— 4ryp.-W NUL
Full Pond/ Normal Mlle _
Shoreline ` 1 ft
Ab— fill pmW NM
2ftx 150 ft
.4tional ckarirq
if necessary
Ml IMI
7/ e
FORM: SSGP 02-2017 I Pian View �� I Page 3 of 4

Lake
(At Full Pond/ Normal \Eater velj
-ts
Side View
U-
10 ft. bank
height
I
Side View
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
'if necessary
I
Existing bank
M P L E
FORM: SSGP 02-2017 Page 4 of 4

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