20190194 Ver 1_Shoreline Stabilization_20190213

r , State of North Carolina
Department of Environment and Natural Resources
10- Division of Water Resources
Water Resources 15A NCAC 02H .0500 - Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL QUALITY FORM: SSGP 02-2017
Shoreline Stabilization Application Form 2 0 1 90 1 94
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 [_3A NCAC 02H .0502(a)]
1. Owner Information
Name: serol '
Mailing Address
Telephone Number:
E-mail Address:
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Fax Number:
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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:
http•//www saw usace army mil/Portals/59/docs/regulatorvlregdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
B. 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, 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 prop" (where work is to be conducted)
County: /' Nearest Town: Alei., - i4rl
Lake/ river/ ocean adjacent to property:
Property size (acres):
Subdivision name or
Directions to site - please
•5m,:
number):
landmarks, etc.:
Latitude (in decimal degrees)-?-r,longitude (decimal degrees):
S. Describe the existing land use or condMon,of t site a be time of this application
(residential, undeveloped, etc.):
6. Describe proposed work (include discussion as to how hardee ing of shorelin as been
avoided, or why ' is n ssary-
7. Will work be conducted from land? From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavation,ckfill, rip rap, retaining walls, etc.) in square feet:
Temporary impa m square feet:
9. Total amount of impatcts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent im a (including back fill,:ca,90on, rip rap, retaining walls, etc.) in square feet:
Temporary impacts (tempgrary
corridor) in square feet:
10. Please describe the vegetation above the normal pool lake level/ Normal
feet landwWd to be injKaacted (number of trees,
11. Signature
IIIU IIJ
Owner/Agent's Signature 115A NCAC 02H .0502(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
Lake
(At Full Pond/ Norma) Water Level) ///;'�ni /lam
c
Full Pond/ Normal Water Level
11=1 MI MI 1=1Shoreline
Plan View
Lake
tk UPOW/ N—W W wLi" Existing Dock
3Uhx/h
V� ^. 311x11111
Fxtox• loll pond/ NWl
Full Pond/ Normal Water Level
hx
ara —
a150h
111! RI p .^ ,.� ..
Abo Ul poaxU NWL
2h.:tso R.
a" ional dex4g
' i1 necessary i
i
IAMPLE
FORM: SSGP 02-2017I Plan View
Page 3 of 4

3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
'if necessary
Existing bank
10 ft. bank
Side Vi
FORM: SSGP 02-2017
AMPLE
Page 4 of 4

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WILLIAM LAMAR: SHEPHERD & WIFE,
CAROL WHITE SHEPHERD
Lot No, 5, Block 1, Unit 1 of tho TlWy Ldta Eetets Oavak7pment
Soutll Alt+emarta township, Sbx4y county. Narfh Carolina
Deed Releranae'Boak 1083 Poga 914, Plot Book 5'Pogo 105.
Sumay.d by Thomas L Fldb, AH.S-2908, 1n November 201&
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