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State of North Carolina
Department of Environment and Natural 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 fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617 2 0 1 8 1 6 5
I. Applicant Information [15A NCAC 02H .0502(a)] �o 41011�
1. Owner Information oz"�
��iJ
Name:
A
Mailing Address: (?-?
X/©2GA?_OS.9 ��4,
Telephone Number: 720 h l Fax Number: - g&7166
E-mail Address: 6fkel ra G o Inns a- t' c a
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.arm .mil 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:/9' A.)N % 2M_S ,d Oc�S 7X,6_�lh
Mailing Address: '0q a. /2d��e _;>O S/
.08 7 3,&
Telephone Number: &7� 2-210 -.20,fMx Number: BZf -;F::e3 P�Z6D
E-mail Address: 0-- -0I. Com-+
Person to receive the Certification Approval: ,,1E07V %��-T7t!✓S
I1. Project Information [15A NCAC 02H .0502(x) & (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
0

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: ► Nearest Town: /O/ P/_Z�A)�J e4 01)
Subdivision name or site address (include phase/lot number):
Directions to site - please include road names and numbers, landmarks, etc.:
/w f�!'z 0 C MOAR ? Ty 1,(-)-¢YrW 2�)
Latitude (in decimal degrees) �� l7/ 1;P5 9' Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): ,plc r !% 4]�� -5-4,��--
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
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:
G 00 -3C F7--
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. e!� 00
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): C,�i✓�r- 1G-+
!3G%
Oct Z2- 2—o
Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSCP 10-2013 Page 2 of 3

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State of Forth Carolina
Depai bnent of Environment and Natural Resources
Diwdsion of Water Resources
15A NCAC 02H .0500 — Water Quality certification, shoreline Stabilization
FORM: SSCP 10-2013
ShoMine Stabi kation Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
Divisicm of Water Resources
401 & Buffer Ping Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
1. Appiicant Information [15A NCAC 02H .0502(a)]
1. Owner information 4
Name: � �� L . -Tlc'/lam' - /r-/,¢ �a9-�Ei ' A-W-IXiETS
Mailing Address:
PC
Telephone Number: 770 �f % Fax Number. - 7
E-mail Address: rr��.�--�x�_ am_0.,` 1_ c a
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/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf1 must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Person to receive the
Aa �.�d, y
l itrf�c NZ. _,-aR73f�,
ax Number.
_ �o�pc�-,b o�► S(� X0_8 /, co-�
Approval: .,?_,o7j1
11. Project Information 115A 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 pian showing property boundaries and proposed locations of
vegetation clearing, structures (buildings, retaining wails, -docks, impervious surfaces,
FORM: SSGP 10-2013 Page I of 3
RI

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: 1 Nearest Town:
Subdivision name or site address (include phase/lot number): 7 -?k Sr�a/zh�LirZift
Directions to site - please include road names and numbers, landmarks, etc.:
f dln�,r► .�1,P Ldp T � Oco IwAl% ff/d, 71>
�AO At
Latitude (in dedmaidegrees) t
Longitude (deomal degrees)
5. Describe the existing land use or condition of the site at the time this plication
•,� cf/ fid
(residential, undeveloped, etc.): ¢
6. property size-(acresY
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how harder of shoreline has been
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avoided, or why it is necessary):
S o�2F.. �i0,� -/- s��'
From water? ]
g, Will work be conducted from land? '� all excavation, backfill, rip rap, retaining walls, etc.)
-1-0. Total amount of disturbance (inciud g
below the normal pool lake level/ Normal Water Level in square feet or acres:
ra , retaining
11. Total amount of disturbance (including all clearing,
back fill, excavation, rip P
above the normal pool lake level/ Normal Water Level and 50 feet land -ward in
walls, etc.) g as � Q �T
square feet or acres:
e the vegetation above the normal pool lake level/ NormaetLevel d
12. Please describ for instance
50 feet landward to be impacted (number of t/r�e��I�
C 02H .0502 Date
own r/Agent-s Signaturef 15A N om the owner is provided-
"Agent's signature is valid only if
On atrfharizatia► letter fi page 2 of 3
FORM: SSGP 10-2013

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State of North Carolina
Department of D ironment and Nature Resources
Dnsion of Water Resources
15A NCAC 02H .0500 —Water Quality Certification, Shoreline Stablkation
FORM: SSCP 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
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
1. Applicant Information 115A NCAC 02H .0502(a)]
1. Owner Information r
Name: �4XAIO� 4 .
Mailing Address:
Telephone Number: /7U ff lh Y,4W Fax Number: V7. Y - tY
E-mail Address: _ !YMA a4o^cr ro ELJ C © Ws a -i I . c o -.
2. Agent/ Contact Person information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http:/Iwww.saw.usace.army.mil/Portals/59/docs/regulatory/reedocs/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.
E-mail Address:
Person to receive the
�ws 040&�s
r_5_6 / V110E. NZ. 2,873A,
-.2VftrFax Number. 8'2F--ZY.X '-AZ40
Approval: 4_07%1 f�9>�77t
II. Project Information 115A NCAC 02H .0502(a) & (b)]
1. Attach a vicinity map(i.e. street map) dearly 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: SSCP 10-2013 Page 1 of 3
RE

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)
AIMWICounty: r�� Nearest Town: %4
Subdivision name or site address (include phase/lot number): 79k Z&fi£ SA/o /0111Z-
Directions to site - please include road names and numbers, landmarks, etc.:
s ,7nan ;CIIOW�fn► 7A-ir !16 rnr✓AN fig/d �tf� 7 0
dtj
OA
ci
Longitude (demal degrees) "
Latitude (in decimal degrees) 3 �7/ plication
5. Describe the existing land use or condition of the site at the ti the p
(residential, undeveloped, etc.): - AM-----
size- (acres)' t q- e/z F
6. Property
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
lo,9%r9�fGlz � ice'}" ----
avoided, or why it is necessary):
9. Will work be conducted from land? ❑
,From water?
avation,backfill .rip rap, retaining waifs, etc.)
-1-o. Total amount of disturbance (including ai Water Level in square feet or acres:
below the normal pool lake level/ Nor
00 �� /C7)65krretaining
excav
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Total amount of disturbance (including all clearing, back fill' Level and 50' feetand-ward in
walls, etc.) above the normal pool lake level/ Normal Water
square feet or acres:
6 no � t� moi.
12. Please describe the vegetation above the normal pool lake level/ Normal ter Level
50 feet landward to be impacted (number of trees, for instance):
RINk z
Q
C O2H .0502 Date
Own r/Agent's Signatures 15�+ N the owner Is Provided:
"Agent's signature is valid only if an authorization letterfr page 2 of 3
FORM: SSGP 10-2013

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