20181420 Ver 1_Shoreline Stabilization_20181017

State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
Division of Water Resources 15A NCAC 02H.0500 — Water Quality Ceratibn, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
2o1 a2o
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
OU 17 2018 0
D Q- ATER RESOURCES
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Mailing Address: 115 ._. 0(y.-.
Telephone Number: r7og- 'irlo - I.S71 Fax Number:
E-mail Address: 0ye c:� Pn,e n n lln D . e6 nc)
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.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:
I Y loore5yi l le , N - x9115
Telephone Number: 70y- CpLh-SI I I Fax Number: 'joy- (clan- 59CQG
E-mail Address: C k0_ $pct �p_lk,D i L%-,►nr`15- e_cc_m. nek
Person to receive the Certification Approval: i4 i c e. L�p
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: M ael l Nearest Town: Moore-Sv Me
Subdivision name or site address (include phase/lot number): a k
�ii�nnresv ill _ NC a$II'1 , I ,m�r �ene Thor W g
Directions to site - please include road names and numbers, landmarks, etc.:
%J I % 'J
Latitude (in decimal degrees)_ 35_ 581oy t(( Longitude (decimal degrees) - Rh _ M3 t3q 7
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): es idc.n4-ia -
6. Property size (acres): . f32.nr_r�S
7. Lake/ river/ ocean adjacent to property: NLorDMy%
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): �5)0,-i4e n nct Sim ►tee , 's �n j -I -I YI
in4 a _l � c IQSs
9. Will work be conducted from land? ❑ From water? Q"
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:
kelcL.1J
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: -L,1 Q.ne ve _
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):
69/3 it
[15A CAC 02H .05 2(f)l Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Lake
(At Full Pond/ Normal Water Level)
Full Pond/
Normal Water Level -4
� M
yo' 7
PitomenG- tyre5l-)cacoC.haSc,-
1l5 14'CLfP3Oa-K
(Y'�aresville, W- x811
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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.
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corridors
FORM: SSGP 10-2013 Page 3 of 3

i �! Ln M 6� &tl A s P A C- 0 C4q A� give
CSC Stone and Recycle, LLC./Natural Grein
Scapes, LLC a01harization to
o lain t1he
necessary information for stabilization and
dredge permits,
Date- !0

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