20181468 Ver 1_Shoreline Stabilization_20181026

State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
15A NCAC 02H .0500 - Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee
should be sent to: -� + a 4
Division of Water Resources
401 Et Buffer Permitting Unit
1617 Mail Service Center 2 0 1 8 1 4 6 8
Raleigh, NC 27699-1617
I. Applicant Information
1. Owner Information
Name: A 11e,c\_ �
Mailing Address:
[15A NCAC 02H .0502(a)]
4bCDO
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Telephone Number: -V4 5qt N1_:�-> Fax Number:
E-mail Address: Katm V Ie -&A- n C -Dov- ff)Ck'co M
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.mit/Portals/59/docs/re_qutatory/
regdocs/Permits/ SAMPLE _ AGENT_AUTHORIZATION _FORM.pdf) must be attached if the
Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Person to receive the Certification Approval:
II. Project Information [15A NCAC 02H .0502(x) 8t (b)]
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.
Provide a detailed site plan showing property boundaries and proposed
locations of vegetation clearing, structures (buildings, retaining walls, docks,
FORM: SSGP 10-2013 Page 1 of 3

3.
4.
impervious surfaces, 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.
Attach a photograph of the shoreline/ buffer proposed to be stabilized.
(Include a scale of some sort- a yard stick, shovel handle, etc.)
Location of the property (where work is to be conduc ed)
County: J Nearest Town: 00'ccs'/'��
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names
numbers, Landmarks, etc.: _
Ir
�u e e �c� t✓ nAC4
Latitude (in decimal degrees) 351 &01,91 q2- Longitude (decimal degrees) —�®'C6-1 3(D 1
5. Describe the existing land use or condition of the site at the time of this
application (residential, undeveloped, etc.): Ce S, k44 t e,
6. Property size (acres):
7.Lak / river/ ocean adjacent to property: fes'' Ox)
8. Describe proposed work (include discussion as to how hardening of shoreline has
been avoided,. Qr why it is necessary):
V' Cox C i 5i C`.S
9. Will work be conducted from land? l4 From water? (\-,o
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:
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:�-V ck cc,
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): _
FORM: SSGP 10-2013 Page 2 of 4

46�CHt-f\- ("+
Owner/Agent's Signature' [1 5A NCAC 02H .0502(f)] Date
'Agent's signature is valid only if on authorization letter from the owner is provided.
Full Pond/
Normal r Level
Shoreline
5�
Lake
(At Full Pond/Normal Water Level)
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

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 4 of 4

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