20181158 Ver 1_Shoreline Stabilization_20180816

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:
If sending via US Postal Service
Karen Higgins
DWR — 401 & Buffer Permitting Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
201 81 158
I. Applicant Information [15A NCAC 02H .0502(a)
1. Owner Information
RECEIVE®
PA r [XUG 16 2018
] NR -LAND QUALITY
STORMWATER PERMITTING
Name: Patrick . & Carol A. Coyne
Mailing Address: 210 N. Main Street, Suite 310
Kernersville, NC 27284
Telephone Number: 336-707-3664 Fax Number:
E-mail Address: [e-mail]
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http://www saw usace army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
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: Montgomery Nearest Town: Mt. Gilead
Subdivision name or site address (include phase/lot number):
Fairway Shores
Directions to site - please include road names and numbers, landmarks, etc.:
From W Main Street, Troy follow NC -24 W/ NC -27W/ Albemarle Road for approximately 12
miles Turn left onto NC -73 E and then turn right onto Lilly's Bridge Road. Approximately 4
miles turn right onto Fairway shores and then left to stay on Fairway shores. Turn left onto
Peninsula Road and destination will be on the left.
Latitude (in decimal degrees) 35.227774 Longitude (decimal degrees) -80.069832
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Developed residential
6. Property size (acres): 1.19 acres
7. Lake/ river/ ocean adjacent to property: Lake Tillery
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Placing new rip rap on shoreline and replacing existing
concrete boat ramp with new concrete ramp — same dimensions.
9. Will work be conducted from land? x® 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:
1058' of shoreline x 6' below full pond is 6,348 sq. ft.
11. 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: 1058' of shoreline x 6' above full pond is 6,348 sq. ft.
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): normal and native
vegatation
FORM: SSGP 10-2013
Date
Page 2 of 3

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Date:06/18/18 - Drawn By: MRI - File 4: 16318
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Date:06/18/18 - Drawn By: MRI - File 4: 16318