20181604 Ver 1_Shoreline Stabilization_20181120

Sime of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
ISA 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 fee should be sent
to:
Division of Water Resources $ P
AID
401 & Buffer Permitting Unit
1617 Mail Service Center 2 0 1 8 1 6 0 4-
Raleigh, NC 27699-1617
1. Applicant information 115A NCAC 02H .0502(a)] OQ �(/ �!
1. Owner information NOV 2
Name: Robe tet- E, expYe aw cl M41 1' .4- L. HV -C 0 2016
Mailing Address: lag Candler' 0a" L & FER ReR u
D -e c-sA r. G- A- 30030
Telephone Number: Ll oq -2-76 --b r? 3 2 Fax Number:
E-mail Address: 9 1-14 O TX -1t Ic =S S 6 qLia Ai 1,
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.mil/Portals/59/docs/regulatory/reizdocsjPermits/SAMPLE AGENT AUTH
ORIZATION FORM.ndf) must be attached if the Agent has signed this application form.
Name: SpA /'vhtl l� V0
Company Affiliation:
Mailing Address:
��- .J>"'/ 44- f_r
Telephone Number:o Z' r/5�� -c�17 Fax Number:
E-mail Address:
Person to receive the 6ertification Approval: Gi i�rlix.ir
11. Project Information i15A NCAC 02H .0502(a) &(b)j
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 wails, docks, impervious surfaces,
FORM: SSGP 10-2013 Page 1 of 3

r ti
etc.), rip rap, excavation or dredging below Full Pond/ Normal Water Levet elevations,
and construction access corridors. You may use the diagram provided at the end of this
application form.
I 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: d Nearest Town: a,,l-Po ' 4 ua �✓
Subdivision name or site address (include phase/lot number):
s� - ' *YJA6-Ze7k(
1
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (m dedm idevrm)—W Z /77 Longitude (dedmw* ries) �-? 6'63 5-iZ
S. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.):lleAl �/T%v.Ydmsii
6. Property size (acres): / t - e f
7. Lake/ river/ ocean adjacent to property:/:1i�rtW�.,I
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): SMI OV5 Aeo rli^l Z,*40�
u/ WJ eAeoloiwS4Wr4az I ; Y 144 4 0.1of-1,
9. Will work be conducted from land?From water. a IV sfi v
❑
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:
o© S Q r
11. Total amount of disturbance (including all dearing, back fill, excavation, rip rap, retaining
walls, etc.) ab ve the normal pool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres: e�; 00 s—a
r
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):%yl/wl•��.n ��rc100
� o ✓� — 49.04 14W-4-- AwO 10V Aho—
AI.#t2�1i T» ,eZ XE-Ov A -9 J - 1VvW1A4 .mss
r/Agent's Signature' )15A NCAC Q2H .0502tfl1 Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

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