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Home My WebLink About20181395 Ver 1_Shoreline Stabilization_20181011State of North Carolina Department of Environment and Natural Resources Division of Water Resources Aw15A NCAC 02H .0500 - Water Quality Certification, SIeli� tion Division of Water Resources M: S G 013 Shoreline Stabilization Application Form 2 0 18 1 3 95 Three copies of the application (including attachments) and the application fee should be sent to: Division of Water Resources 401 Et Buffer Permitting Unit 1617 Mail Service Center POCT Raleigh, NC 27699-1617 D 1 1 201812 � Applicant Information (15A NCAC 02H .0502(ai] 1. Owner Information L4DO-4-BUFF RRPERMInIN� Name: � a �- �` ��' � `' `�- Mailing Address:Z- 1 bfav /w _ 144 C✓ 2i&OD Z Telephone Number: 7041 4 - a)VZFax Number: %0,! .- 5lg E-mail Address: a L", evowjLoa gy Q G`�'�✓� 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.armymiI/Portats/59/docs/re-gulatory/ regdocs/Permits/ SAMPLE _ AGENT_AUTHORIZATION _FORM.pdf) must be attached if the Agent has signed this application form. Name: D Rn VJGA�(Iut Company Affiliation: CDm0 'CnC Mailing Address: 03 '..l Telephone Number: -104- 00A H-3 1514 Fax Number: E-mail Address: k-J0'k\0'_c.e,6k14 (M"l a com Person to receive the Certification Approval: II. Project Information (15A NCAC 02H .0502(a) Et (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, etc.), rip rap, excavation or dredging below Full Pond/ FORM: SSGP 10-2013 Page 1 of 3 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: fy)&MaOMP.cU Nearest Town: NbRMAI. Subdivision name or site address (include phase/lot number): WOCIAVXIA's to site - please include road names and numbers, landmarks, etc.: _ Latitude (in decimal degreespu) 1 1 0 1. 1 Longitude (decimal degrees) 5. Describe the existing land use or condition of the site at the ime of this application (residential, undeveloped, etc.): \a 6. Property size (acres): 0- 31 OM 7. Lake/ river/ ocean adjacent to property: \UL r\ lc 8. Describe proposed work (include discussion as to how hardening f shoreline has been avoided, or why it is necessary): 9. Will work be conducted fro AiFrom water? 10.Total amount of disturbance ding all excavation, backfill, rip rap, retaining watts, etc.) below the normal pool lake level/ Normal Water Level in square feet or acres: 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: I0U \" aM Sa 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): _ lRop Omo \A o* \- Z-�Nuh o' (x N&( acs m� VNON A\qk ra6 �o be. c b, 6 v4 % we,\\ �a\un 1 FORM: SSGP 10-2013 Page 2 of 4 1 Owner/Ajent's Signature 5AJQC 02H .05 2 f Date "Agent's signature is valid only/ an authorization letter from the owner is provided. Full Pond/ Normal Water Level rM am OM on ow Shoreline . UQ t-AO'Aw(N includes d i. ril+lvm,W VIM5 *,o�k Vic, k w-eMaVeA a5 well ag 0, jkW w y Vto V*'tV\.I '04 V S1V(-(Av'L brx\v, Lake (At Full Pond/ Normal Water Level) o�caYt,1 ta0.d c�cSS MW =0 � MW no A "t'i SP&WG ki Int b\\ � lOGA\o(\ o's a\d .SCA WU.\\ Please approximately sketch the following information on this plan (provide dimensions for each item, such as 10 ft x 100 ft)": 1. All proposed vegetation clearing 2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation 3. 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. FORM: SSGP 10-2013 Page 3 of 4 4 Montgomery County NC WebGIS N: 572194 E: 1678444 Lat: 35019'02.7", Lng:-80004'40.7" Results Print Format: Map only File Type: JPG Size: screen 'R-1421 C40Ai U You must allow pop -ups for this site. 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