20190217 Ver 1_Shoreline Stabilization_20190214

20190217
State of North Carolina
AM environment and Natural Resources
R MA510n of Water Resources
Dhislen of Mid Resc'smes 15a HC.1C 01M .0500 — Water Quality Certification, Shoreline Stabilization
FORM: S5GP 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 (15A NCAC 02H .0502(a)1
- 1. Owner Information
Name:l Zee,
Mailing Address, �� q� �
Telephone Number. 9W Ifole _1424, Number:
E-mail Address:
2. Agent/ Contact Person information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
htto://www,saw.usace.amw,rri] Portals/s9/sbtsl��,r�Ip rrm / P�RUTH
O RATION FORM pdfi must be attached if the Agent has signed this application farm.
Name: 90deT[( hW
Company Affiliation: S
Mailing Address: 105'tg._.J%'( &1A OS4
, NC- 2-11 ;21
Telephone Number: 0 - Fax Number:
E-mail Address: �i ! i wind ftea-n!:,+—
Person to receive the Certification Approval:
11. Project Information 115A NCAC 02H .0502(x) & (b)1
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,
F0fL%4. SSCPv 20-2013 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: Gtl11 _ Nearest Town:
Lake/ river/ ocean adjacent to property: 'j ifte roi
Property size (acres):
Subdivision name or site address (include phase/lot number): __ _14 tfe4,
ShOr�S _
Directions to site - nlease include read names and numbers, landmarks, etc.:
2� 12,77-� rr� ort ,?k;�,enn rf' f
LdlilUde lin decimui degrees)
Longitude (decimal degrees)
5. Describe the existing land use or con ition of the sit at the time of this application
(residential, undeveloped, etc.):
6. Describe proposed work (include discussion as to
a oided, or why 'it necessary): G IAC.
!-�S • cmr,�' a wcvd
7. Will work be conducted from land? X
w hardening of shoreline has been
. i
eQI�Jc1.(_
From water? El
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavatipn,
T X 12 &' = _?el % .4r **h L, Mow
Temporary impacts in square feet:
I, rip rap, retaining walls, etc.) in square feet:
don d
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impactsincluding back fill, excavation, rip rap, retaining walls, etc.) in square feet:
16f
:WAG 611VLAX& pkn4 .
Temporary impacts (temporary clearing, construction corridor) in square feet:
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50 Iv
feet landward to be impacted (number of trees, for instance): D 4reGS oni ll
L�IRri
11. Sig�
Owner/Agent's Signature` [ 5A NCAC 02H .0502(f)l Date
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 of 4

d
3 0'6�
10
Side Vi
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
if necessary
FORM: SSGP 02-2017 Paee 4 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/ Normal Water
'— '1horeone
Lake
;At Full Pond/ Nana, -
Plan View
FP3W 5SMi�012:2bO 71
3ftxl50ft
Below full Pond/NWL
r "
1itx 1i0h
Ab—ful, pond; NWL
Faye 3 of 4
Pae= 3 of 4

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 4 PLAN NO. PARCEL ID: 1,0,5-116
STREET ADDRESS:
Please print:
Property Owner:
Property Owner:
y o 0 q -R-f
V1 jvm /
The undersigned, registered property owners of the above noted property, do hereby authorize
fdJm �� ` I� f� of Cdl f S� lin � CTZ? r S
(Contractor / Agent) L (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
Telephone: x I Md -11 ?16--CW5
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Author zed nggature
Date:
Pie" 0""Q2
Authorized Signature
Date:

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WEB HOSTING
STMV COUNTY
1103
Excel 2000/2003 Results
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THIS IS TO CERTIFY THAT ON THE1�_DAY OF 1 ` j 1. SURVEYED THE PROPERTY
SHOWN ON THIS PLAT. AND THAT THE TITLE LINES AND THE WALLS OF THE BUILDINGS IF ANY ARE
SHOWN HEREON.
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ORAN M. BOSTIC REE: 281-561
LOT 5 PLAT BOOK 5 PAGE 60
IRON FOUND
LOT 8 TILLERY SHORES DEVELOPMENT ADDITION
PLAT BOOK 5 PAGE 60
BOUNDARY SURVEY
LOT 6 AND 7
TILLERY SHORES DEVELOPMENT ADDITIOiN
SCALE 1 INCH - 40 FEET
THE PROPERTY OF MARY G. AND RONALD L. PARTRIDGE
MAP RECORDED IN BOOK 5 AT PAGE 60 DEED RECORDED IN BOOK 951 PAGE. 559
NORTH ALBEMARLE 4�1 TOWNSHIP STANLY COUNTY NORTH CAROLINA