20181728 Ver 1_Shoreline Stabilization_20181219

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 d be sen
to:
Division of Water Resources
2
401 & Buffer Permitting Unit 8
1617 Mail Service Center ,Z 728
Raleigh, NC 27699-1617
I. Applicant Information 15A NCAC 02H .0502 a
1. Owner Information 1
Name: L (I SY1 _4e)n
Mailing Address: 7 qOa Ko r mart (1eu, +
Telephone Number: 414 - 621 • 2kUaLfl Fax Number:
E-mail Address: d&c,6e t -�^ 2 o An Im
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: YF �,ra-� �r��p_►n jCT_g, SelcVlces . LLC.-
MailingAddress: ED 0-y' rim
15,
Telephone Number: -7b14 - JgJ1/) - 51 i i Fax Number: "10q - (n(vn- S4Coq
E-mail Address: C 6r- Sem 15 r7 rte" ndl reLim. ne-4-
Person to receive the Certification Approval:
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: L nrj:11 n Nearest Town: [)e.nye.r^
Subdivision name or site address (include phase/lot number): '190), t4orrron (26,)6-
nv r_ Kie- ama-1 L,o} 13 5{-c''io LJ'etapari SJ6(iiU isivn
Directions to site - please include road names and numbers, landmarks, etc.: _rr71 K
4o ex',i- 1113 Qrr NC 16. Mexme orrin Me. IL,N_Turn oigM ung ;r^',S+ClU6Dr.
Turr.kelrkOni6OT-rl0.nolcG{e-„T�rn IeP+ ank NC IG au5'.nesS 9.Trn nahi'a�n&
Ld1 FL
'el res+Ed. ;nue onto I wo 6ore� S .Turn Ie�+ en4 Norryy nC+.
Latitude (in decimal degrees) 35.55044 718 Longitude (decimal degrees) —
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): j�eb l den- ,(Lk
6. Property size (acres):
7. Lake river/ ocean adjacent to property: tS16r nno.n
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): '.4r�e.. 5 )o ire_ . i ns4l ma,+I i n4
0-nd r', n rn J
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:
3' eve ow
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: t a -Ann kle_
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): n rQSS
no -{-reel rc.MnQed no d itrtv r6a n C -e_ -o 62:�
Owner/Agent's Signature" [15A NCAC 02H .0502(f)]
121[2'58
Date
`Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

r La ke
G� ✓� (At Full Pond/ Normal Water Level)
�J
1
3 below
Full Pond/
Normal Water Level
Shoreline
eV lent h
No +Y-eeS removed
�Iv di4U(6ance'
-tom b��Fe�z
�av►d �hetk�n
'1q c) a
be.hv er, NC. a 803'
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

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