20181603 Ver 1_Shoreline Stabilization_20181120

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 Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fe hA&ALIALs t
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
Name:
Mailing Address: 1141 0-1kipe-I
Telephone Number: III -416-q'5140 Fax Number:
E-mail Address: 02Z3_1
2. Agent/ Contact Person Informat
20181603
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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/regulatorylregdocs/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: "J04 ' Calo0 —51 / J Fax Number: '18c! - (nLn ' 5gco q
E-mail Address: 0_62 S t i)a I1,6 �)i u) tnd;b }-reU..m. ne*
Person to receive the Certification Approval: TSa,Ylic P_ �, 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: =,.e l Nearest Town: lrnoores
Subdivision name or site address (include phase/lot number): l4 l Union C%a"A h-,
KC o) P3 It I L6+ _'h e. IDo i n+ o n NLo r mcg
Directions to site - please include road names and numbers, landmarks, etc.: 1111 N
-� eac'►�- 3�i �� 3r�\e�c Sek�ool �l . keeo (e_� at -k �o r K y � f l�� s.o ns
:-
Avk 15} ex',+,n6 4kIn'is_Dr. lyre, Iek 4�on6Ie_reawRo�n4-tL. rn riah-�onlr. Rri-Kk'i�tr1
Latitude (in decimal degrees) 35 , 535133 Longitude (decimal degrees) — W, 9dej 9 (o ( or lei}
o n -k -o
5. Describe the existing land use or condition of the site at the time of this application Union C Uf A
(residential, undeveloped, etc.): i dent"
6. Property size (acres): . '7 f /7 6-0- Ire',
7. Lake/ river/ ocean adjacent to property: Ko r rno-n
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): s%CLcw- to oe_ m i _� CL inS�(l l
—rive -y- roch
9. Will work be conducted from land? ❑ 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:
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: I l Q no\/2
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):
Owner/Agent's gnature' [15A NCAC 02H .0502(f))
Date
`Agent's signature is valid only 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)
5 I 6e-iow
a' 6ejow
I' 0-6ove_ I I 1 a. �0Ve-,
k 50' le -n3+ )
N. d i 54,-)
fo leer
�'Ao
removed
furl-" � CU roi ; n e- W cLre-r
ly 1 Urtkoo 01"(;Lpe1 Dr.
Y�ooresv� l le, f�1C as Ill
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

--- C� l,ln.�. 1�✓ru.,� give
CBC Stone andeccleep LLC./Natural Green
Stapes, LLC authorization to obtain the
nef-wessury, Information for stabilization and
rec�ie Permits,
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