20181206 Ver 1_Shoreline Stabilization_20180829

State of North Carolina
2 0 ' i 2 O lepartment of Environment and Natural Resources
Division of Water Resources
1SA NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
�'vy,.- FORM: SSGP 02-2017
Shoreline Stabilization Ap6iotication 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
A. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: C- [��l
Mailing Address:
Telephone Number:
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:
http://www.saw.usace.armv.mil/Portals/59/docs/reRulatory/reRdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name: a --pe-cc,
___
Company Affiliation:
Mailing Address:
Telephone Number: - 3 Fax Number:
E-mail Address: \t 1 CSS � uahc)D. Cpm
B. 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, 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: Nearest Town: l . CY, I-eO A
Lake/ river/ ocean adjacent to p erty: 10,6 _TW -Q n. 1
Property size (acres): 1 5 3 ac IreS
Subdivision name or site address (include phase/lot number):
VZ
Directions to site - please inc ude road names and numbers, landmarks, etc.:
Latitude (in decimal degrees) •a� X135 Longitude (decimal degrees)-& ,
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): ie_' t&121e��APC�, �
6. Describe proposed work (include
avoided, or why it is necessary)
7. Will work be conducted from land? 9
as to how hardening of shoreline has been
From water? e
8. Total amount of impacts below the normal pool lake level/ Normal Water Level
Permanent impacts (including all excavatiariebackfill, rip rap, retaining walls, etc.) in square feet:
Temporary impacts in s are feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent jmpacts (includin&back fill, excavation, rip rap, retaining walls, etc.) in square feet:
Temporary impacts (temporary clearing, construction corridor) in square feet:
Zj�� _ 2 Z--
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level 50
feet landwpf;lto be impacSed (number of traes, for instance): Zns' .5 rr�
11. Signat
- I rIN
Own Agent's ignature (15A NCAC 02H .0502(f)) 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/ Normal Water
Shoreline
Plan View
Lake
(At Full Pond/ Normal Water Level)
� tr
Page 3 of 4
Lake
(At FIA P=& N=W VAWLevel)
EAstinEOock
30fta7ft
3ftt1SOft
4ffipm4ftxboft
a.a.hawwNWL
Full Pond/ Normal Water Level
—w�
Above full Pd NNWI
zft..iwrc
add fi." ckafa g
• g �nsary
EXAMPLE
1.
FORM: SSGP 02-2017
Plan View
Page 3 of 4

l'
A/
W
Lake as
(At Full Pond/ Normal ater �evel)
L
o °
Z n
-a
Side View
10 ft. bank
height
Side Vi
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
*if necessary
Existing bank
f yea
QO
QUO
FORM: SSGP 02-2017 Page 4 of 4

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Survey for CAM DEVELOPMENT PROPERTIES INC.
CURRENT OWNER. JUNE D. ALLEN
Subdivision THE LANDING - MAP 2 OF 3
Lot(S) 18 PLAT CAB. F SLIDE 49-A
Tax Parcel 6575-18-31-9934 DB 603 PG 759
Street Addrm 249 LANDING TRAIL
Township PEE DEE County MONTGOMERY State N.C.
LAKE TILLEW /
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RUSSELL H. HUNTLEY and
JENNIFER CHRISTINE HUNTLEY
LOT 17
DB. 803, PM 189 /
TAX REF. 6576-18-31-W76 ICV-\ may.
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PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO.
STREET ADDRESS:
Please print:
Property Owner:
Property Owner:
- PARCELID:
The undersigned, registered property owners of the above noted property, do hereby authorize
: -�iw -
- L , . Of &,kyup'4�
(Contractor / Ag &) (Name (ting 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):
Telephone: 2� �Q M'�- UM
We hereby certify the above information submitted in this application is true and accurate to the
best of our kndwiedae.
Date : - =13- t Z Date:
zed Signature