20181312 Ver 1_Shoreline Stabilization_20180927

State of North Carolina
Department of Environment and Natural Resources
DWI
Division of Water Resources
Division of Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application RotXdPent
to:
Division of Water Resources
401 & Buffer Permitting Unit p�
Q
-p c
1617 Mail Service Center �j , ��7
Raleigh, NC 27699-1617 \v 2 0 1 8 1 3 1 2
Applicant Information [15A NCAC 02H .0502(a)]
1. Owner I
2
Name:
Mailing
Telephone Number: d1. -J_,J-JJ_�)7Fax Number:
E-mail Address: JU)L t'f f � �' � Oct f 0> > nC&_ (0 CV)
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.miI/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:
E-mail Address:
Person to receive the Certification Approval:
Fax Number:
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
Pagel 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),2::A n
County: �V Nearest Town: _ ��r
Subdivision name or site address (include phase/lot number):
r _ I I _ 1 A% A .. w
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (in decimal degrees), • 0150 /8 Longitude (decimal degrees) 00 • IooW
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): d6 of 10 NA nU �*QXIMQ
6. Property size (acres): Q
7. Lake/ river/ ocean adjacent to property: Ul_U 1 1 \ Wr
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): ,G"4 4/ A"V_X './ uwg✓ c yc+rs aso
<;-01 /', •li G , fW C 7 % 6/�f xf "Vf
9. Will work be conducted from land? OK 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:
S'74 sq 311-
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: 3rvo"V
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): _
&V/404iy 2k
/T"/ /1.*/.. --
UwnefIreis
ature` [15A NCAC O2H .O5O2(f)l Date
'Agaalidonly if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Full Pond/
Normal Water Level
Shoreline
La ke
(At Full Pond/ Normal Water Level)
dr
y6�3'x
�1 U
6-0,
O 0�00 0 cif
8 0 0
1,
a
1 �
l
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft)*:
1. v All proposed vegetation clearing
2. , Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
3. i 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..,V/f Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. J Location of construction access corridors
0
FORM: SSGP 10-2013 Page 3 of 3

Record orth
D.B. 751, PG. 14
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LOCATION MAP (N.T.S.)
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THIS MAP MAY NOT BE A CERTIFIED SURVEY
.a Ran., set
Tillery Beach / P.B. 2, Pa. 108 On-Lbm0103.81'
AND HAS NOT BEEN REVIEWED BY A LOCAL
e`eysy,4
\ GOVERNMENT AGENCY FOR COMPLIANCE
Dixie Land Surveying, PLLC
License
WITH ANY APPLICABLE LAND DEVELOPMENT
No. P-0335
4978 Country
REGULATIONS AND HAS NOT BEEN
Club Road, Wadmb en N.C. 78170
�\ REVIEWED FOR COMPLIANCE WPI'H
Phone: [phone]
enu0: divlola®windautanl.not
� \
RECORDING REQU{R%M7lr'(VTIR FOR PLATS,
1' Jaw" R Clay, et -UX QL\
C \ D.B. 957, Pa. 730 \
1`1111:61174-03-09-6299
Lot \P.B. TTWq / Heath / P.B. 2, Pa. 133
'cagey Janos Balecom, et -al
0.1 1360 PG. 525
1 I
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Lot Na 175
.a Ran., set
Tillery Beach / P.B. 2, Pa. 108 On-Lbm0103.81'
On -14,. L3 Q4 7.16
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North Carolina, Stanly County
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dwerollim reseeded m atria
D.H. 1614, P0. 693 / PHII 6874-03.03-5136
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art an trltadrlr ail nrr/M an nMaA/ 14/3'13'11 �
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Lot No. 178 /S
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Notes: (z if applicable)
X L t s 3's 0.14 •woe arra alar d lar w
X a M dart. a 1 abeam sh14 aaraaarar
aid sla M ayM.d y a am rd..
• as df. 0 4 a.13'13'. pad Sar. dtaa
seem. w4
X 4. Amour" ow daPaaal.a
A Nt
Lake Tillery
creage sea_________________
Deed Acne• 0 15 A - 6 599 2
L -- t---- "WNW
drag sair as syw.rra am
aaeM aro ad. V . .
saps
crag ler saw.ra. M cif V
.pwla.Yr ad Yat I aaad 61L
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afaaaa aspalea" 9aaa lar —
aaa.a. ea a.. Imran 3'r♦ I
vino— Ns 11-1— rd r —
lasla aw MMd M AO (W >•
a detemsr lease t IISY/1as op.
aINOt Mt& I ININ..Ib
Plat of Property of:
oleo
Breck Lynn Gillespi
Surveyed For:
oro
Jeff Burris
. cres I . SQ. FT. Norwood Twap., Stanly County, N
Boundary Line Agreement Acres + 0,02 Acres - 880.1 SQ. FT. Property Located at: 550 Lake Hea<
----------------------
New Total Acres - 0.17 Total Acres r 7479.3 SQ. FT. Date: x/14/18 - Drawn By: MRI - File N: 15018
Revived: 6/77/18 / Revised: 7/20/18 /Revised: 7/27/18 / Revi