20190304 Ver 1_Shoreline Stabilization_20190306

r State of North Carolina
Department of Environment and Natural Resources
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
Three copies of the application (including attachments) and the application fee should be sent to:
I'll
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 BraTh
1617 Mail Service Center 512 N. Salisbury Street 0 1 9 0
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information [15A NCAC 02H .0502(a
1. Owner Information
Name:
rs r o"
Mailing Address: J 50 loeGc,% I'CGL 9C'�fIG AL, .
Aflavil-c, GA. -30305
Telephone Number: / yLY-4 5 50 51,7/ Fax Number:
E-mail Address: 111 S4 /CS r,w\,
2. Agent/ Contact Person Information
304
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/reQulatory/readocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name: 'S coil qct clk'
Company Affiliation: O I t✓ k (Ic a^ G k x G0
Mailing Address: 13 /! h >C.k n C k
1?oL6;zS v�'Ile, A/C a
Telephone Number: 09,04/79 0461 Fax Number:
E-mail Address: Sc-offJc '. (,ate- 4. 0 -_ pr ra I
UC.tII
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 property (where work is to be conducted)
County: 9 r ah eto\, Nearest Town: _San f 6 c d rk
Lake/ river/ ocean adjacent to property: _ r , , S G eef )0
Property size (acres): 1 c
Subdivision name or site address (include/phase/lot number): / ori RoLt )I)Su dle C.
I93 w c3Y ',f b / fve-/► for .So n feG /k4 /_ tvtn o'n 1'0 /Ya fct 'Jot
Directions to site - please include road names and numbers, landmarks, etc.: J-ra ►
/S /, Zc.� r.-% a � k, o" wyi 61n ; lI A u u sc a n
Latitude (in decimal degrees) 35, 'IrKKO 10 Gco Longitude (decimal degrees) -V-' - V C1 *7 16600
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): P. -S ► CL nfifA( Sunrnrney' kc, kL hOU3&
6. Describe proposed work (include discussion as to how hardening of shoreline has/been
avoided, or why it is necessary): flcp(ac.G
r -r- k'l& I' P) I n � GJ '^- i !
7. Will work be conducted from land? P11 From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavati
[)r-" ia.cA Stone tP� G,
Temporary impacts in square feet:
backfill, rip rap, retaining walls, etc.) in square feet:
)Q (e Cou"e-I rUr oc--j UJa(/
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:
Temporary impacts (temporary clearing, construction corridor) in square feet: 1
Mctr_k,ncca cc©s5,nr C.>'s,f ,'n o,r
c, "A _J 2 f �'1• t'
V IJ
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):1 / S MoL d /a,no� S//1G4nL,
SAt_Ubl �v��t USO 0k�Crk i-5/01) VeUiifcrn_, SUP !Gcc Jc, Aori rcccot�_
/-c n'1 o cAc,! CU �S trc�G IrG Y�
11. Signature
Owner/Agent's Signature* [15A 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
In tr�o� PC n�
Co�'iS �rvLC7t'�
4T
Full Pond/ Normal Water
Shoreline
Acce 5J,
Plan View
La ke
(At Full Pond/ Normal Water Level)
Oec,�
/4v v ;-
r �e- Aocc -
�, whaler
CJJ 6.sr;
OL C c (,- 5-5
FORM: SSGP 02-2017 Page 3 of 4
Lake
(At Full Pond/ Normal Water Levet)
Existing Dock
30Itx7ft
3Itx150 ft
Bel—full pond/ NWL
Full Pond/ Normal Water Level
7horeone — —
_ —4It0f
Riprap
Ab ehull pond/NWL
2 ft. x 150 h.
additional clearing
" If necessary
E
AMP
E
Plan View
�, whaler
CJJ 6.sr;
OL C c (,- 5-5
FORM: SSGP 02-2017 Page 3 of 4

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SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION: gable 4
PiF
LOT NO. 2y� �``k'' t� PLAN NO. QA t K4 , PARCEL ID: 5(04 2-04 iA0oZA
STREET ADDRESS: 3l (--4- 1 Vic 2stiZ (
Please print: I 6(0
Property Owner:P-
Property Owner: L-0 r,
3
The undersigned, registered property owners of the above noted property, do hereby authorize
S cJ�'' q��L, of Lk
�lun t 1-lt c a v c C;
(Contractor / Agent) (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):
TSO Aue 4(A—. C� 3x305"
Telephone:
`}0A-5S0—St-1
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.

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