20170839 Ver 2_Shoreline Stabilization_20190115

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
N. 1
Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL QUALITY FORM: SSGP 02-2017
Shoreline Stabilization Application Form_T,
Three copies of the application (including attachments) and the application fee should be sent to:
If sending via US Postal Service If sending via delivery service (UPS, FedEx, etc.)
Karen Higgins Karen Higgins
DWR — 401 & Buffer Permitting Branch DWR — 401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information [15A NCAC 02H .0502(a)l C
1. Owner Information \�J
Name: Douelas Mav
Mailing Address: 467 Maple Ln.
Danville VA 24541
Telephone Number: 434 770-2216 Fax Number: none
E-mail Address: [e-mail]
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter must be attached if the Agent has
signed this application form. (A form can be downloaded here:
httD://www.saw.usace.armv.mii/Portals/59/docs/reeulatorv/reedocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.Ddf)
Name: none
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
B. Project information [15A NCAC 02H .0502(a) & (b)7
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, buildings, retaining walls, docks, impervious surfaces, 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.
FORM: SSGP 02-2017 Page 1 of 3

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: Person Nearest Town: Leasburg
Lake/ river/ ocean adjacent to property: Hyco Lake
Property size (acres): 1.68 acres
Subdivision name or site address (include phase/lot number):
257 Fletch Ada Ln., Leasburg, NC 27291
Directions to site - please include road names and numbers, landmarks, etc.: From Leasburg,
NC 158 E 1.2 mi to Ralph Winstead Rd, N 2.6 mi to John Brewer Rd., E.9 mi to Fletch Ada Ln.
Latitude (in decimal degrees) 36.4234 Longitude (decimal degrees) -79.1070
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): residential
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Removal of existing deteriorated stepped timber wall.
Replacement with rip rap along the embankment.
7. Will work be conducted from land? K From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
Replacement of about 2 x 65 feet of rotted or missing timbers with ria ran. No excavation.
---- ( 13 O
Temporary impacts in square feet:
No additional impacts
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
z
Replacement of about 4 x 65 feet of rotted or missing timbers with rip rap. No excavation. (Z6 o �(
Temporary impacts (temporary clearing, construction corridor) in square feet:
No impacts
10. 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): Lawn, landscape shrubs.
No trees are present within 50 feet. A retaining wall is ^20 feet back from shoreline.
11. Signature
Owner/Agent's Sign ture [15A NCAC 02H 502 f Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 of 4

12. Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
Full Pond/ NSI
Shorelir
rip
Plan View
Lake
(At Full Pond/ Normal Water Level)
r
Full Pond/ Normal Water
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Arhdrinnal r�eAring
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lase
puna P..V W—W VA&. t-41 Existing Dock
30 ft.7 ft
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FORM: SSCP 02-2017 E AMPLE
Plan View
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Page 3 of 4

Lake
(At Full Pond/ Normal Water
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Side View
10 ft. bank
Side Vi
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3 ft. below full pond water level 4 ft, above full pond water level 2 ft. additional clearing
*if necessary
Existing bank
FORM: SSCP 02-2017 Page 4 of 4

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