20181332 Ver 1_Shoreline Stabilization_20181002

2©181332
State of North Carolina
Department of Environment and Natural Resources
x _ Div€;ion of Water Resources
Water Resources 15A NCAC 02H .0500 - Water Qtiality Certification, Shoreline Stabilization
ENVIRONMENTAL QUALITY 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 PermittingZrO
@
1617 Mail Service Center 512 N. Salisbury Street L5 LI V l5 D
Raleigh, NC 27699-1617 Raleigh, NC 27604 C 0 2 2018
A.
Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information jj
Name: _W11 l � 1 1�C_I��I
Y
Mailing Address: 12- ( E' 1 e'rIt-S k �-
(4< 7
Telephone Number: 3 _>
r
o
7l-ZI0C%
E-mail Address: ('a�c�y & Lv Fc
6 F
L Z72-
Fax
7Z
Fax Number:
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.miI/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTHORIZ
Name:
Company Affiliation: I ).--
Mailing Address: 1 fir( �0 V✓ �3 w� 4 Aue— S ­4'rC 2%-%
Telephone Number: 706(-o2 7 Fax Number:
E-mail Address:cs���
B. Pro' t 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.Ile` 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. LocationCf the property (where work is to be conducted)
Nearest Town:�—
Lake/ river/ ocean adjacent to property: —v"
Property size (acres):
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (in decimal degrees)�5Longitude (decimal degrees) ci
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):�S:�x1��a�
6. Describe proposed work (include-iscussion s to how hardening of shoreline has been
avoided, or why it is necessary):-`\�-�����
7. Will work be conducted from land? 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:
6 � -S-.3, -F
Temporary impacts in square feet:
NUge__
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:
46 h'
Temporary impacts (temporary clearing, construction corridor) in square feet: I�
- /(}o G4,P41­7g j A� C -A -T i/c"`S @ h44AL
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): QAC c i rr—zS `^
a,�v�l, u-�1rJ S f+C� Ve5e,f-.a*`� Cd S4.,Ir' <<kA�L
11
Signature
-;;��
Owner/Agignature' [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 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)
c
z Z
v�
G
'!:� 6*-�'-� a
FORM: SSGP 02-2017 Page 3 of 4
Lake
IAt Full Pond/ Normal Water
Level)
Existing Dock
30 ftx7R
3ftx150h
Below full pond/ NWL
Full Pond/ Normal Water Level
r—'I reone --
— Oft. 150ft
Ri prap
Ab— full Pond/ NWL
2 ft. X 150 ft.
addidonal clearing
` if necessary
E(AMPLE
Plan View
FORM: SSGP 02-2017 Page 3 of 4

io'I _
La ke
1
(At Full Pond/ Normal Water Level' M
C
t>a
E
L 0
O =
Z (n
C
Side View
ILL
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
if necessary
Existing bank
10 ft. bank a
height Dye
I I r6
• — jZ73&2LI,
FORM: SSGP 02-2017 Page 4 of 4

lernmer
�'� fir' ' ,.�•. �,�'�r,'
s Avenue
28673 l 4a.,` " ..,y;r� r t.�' : ' • 1yy.•♦ #: �r/•�i
k _ _. ,�y�• 4'. . , R •N it et: A_'}R�+- � J. r - � ` ar C. `� •l" 1
OF
.-
H
1y ,qty,
vp
j.
• T �/�� g�� ry �� ' ~ W �. •tom'
ow
AV,

• �� � ice. � Y'r� ',4�',
r
.ir "71`;, Y7� •,�a��•' 1 ciAm
d ..
Y
(_'
PTa

S)o ,
4.78
AX,O�
LOT 42
.J.�") n CK nr%0V
It , f
.90
1. PI1y \ \
44 1�
ACRES
i
qty t !
�p�h y`, • ,9�'1,
Approximately 223 Linear feet of shoreline to received Class "B" Rip Rap

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 44 PLAN NO
STREET ADDRESS:
Please print:
Property Owner:
Property Owner:
PARCELID: 4616013507670000
4760 Giles Avenue Sherrills Ford NC 28673
William H Clemmer
The undersigned, registered property owners of the above noted property, do hereby authorize
Randy Jordan of Lyfe Marine Inc.
(Contractor / 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):
1216 Yorkshire Dr High Point NC 27262
Telephone:
336-841-2100 or 336-667-7774
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature
Date: % Z y ��
Authorized Signature
Date:

•-«�'W.,.
� M. d �I •��+�' ���ltll'�. .'tai � t {�`�,f �� �" F�� � ;if
�T ^ ` I . Com• , .� • 3[T�. f . a l . v 11. � ,�sy�� _ t~ fI ` !'+, � + t ' " i
� Y jiy�L� d !,�Rl,'�_Y � .� • 1 'i ,�`, J � z ,!L' � •/_ 4,• � �j �
.t0�. F re Y f 1 • . a ` u.La. . -ri" •�`j �� '! � . � ly �,� F k •, 1r�.. ] .F' a �}'� � .

-t, `y7,x• c.4. ``: r,' k sir .may.. ,y .'
�' � r � ` r fr.- _• � '`.. f 1� `�;. yf R. �-^ F�iy Vii. k
17S
_1i
` t
!�r
r.
i�
(rj1 y t
{1