20190407 Ver 1_Shoreline Stabilization_20190401

C_
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:
If sending via US Postal Service If sending via delivery service (UPS, F�IF,�A'1��
Karen Higgins Karen Higgins r
DWR — 401 & Buffer Permitting Branch DWR — 401 & Buffer Permitting Brant
1617 Mail Service Center 512 N. Salisbury Street 2 0
Raleigh, NC 27699-1617 Raleigh, NC 27604 9 0 4 07
A. Applicant Information [._5A NCAC 02H .0502(a)]
1. Owner Info
Name:
Mailing Address:
Telephone Number: /t-"% /
E-mail Address:
2. Agent/ Contact Person Information
Number:
a'//you �� •- /,��
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/regulatory/regdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
B. Project Information [15A NCAC Q2H .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: h&4-ovm r. Nearest Town:
Lake/ river/ ocean adjacent to property: - 3— f"�-S'�e�
Property size (acres):
Subdivision name or s (include phase/lot number): L .�
Directions to site - please include road a and Im ,landmarks, etc.:
Latitude (in decimal
Longitude (decimal degrees) • D�Oo�
5. Describe the existing land use or Gondi n of the at�yme of this application
(residential, undeveloped, etc.): �S�
E'd!r--'g'
6. Describe proposed work (include d' as law ha ni been
avoided or why it is rosary) �� �iie-J�7����
7. Will work be conducted from land? gr--� From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
backfill, rip rap, retaining walls, etc.) in square feet:
Temporary impad;,ifn square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including back fill, vation, rip rap, retaining walls, etc.) in square feet:
Temporary immporary clearing, construction corridor) in square feet:
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level 50
feet landw to be imps d (number of , fo ' nee): G'o
11. Signa
er/Agent's Signature (15A NCAC 02H .0502(f)l Date
Agent's signature Is valid only if an authorization letter from the owner is provided.
FORM: SSCP 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.
n i nrarinn of anv Pxravation or dredging below the Full Pond/ Normal Water Level elevation
Lake
(At Full Pond/ Normal Water Level)
SIP
Gtr �
c�l eta
Full Pond/ Normal Water Level
Shoreline C
Plan View
FORM: SSGP 02-2017
Lake
jAtF P.WNO11' Mm L-9 Existing Dock
/30 tt■7ft
A 0 MWX P L E
Plan View
Page 3 of 4

��f C /
l( CO G(
(At Full Pond) Normal W er Level
a)
o
s
:N
- ------------ -- — - - — -
C
Side View CL
U-
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
rf necessary
Existing bank
10 ft. bank a
height
COQ
L L
Q
Side View
FORM: SSGP 02-2017 Page 4 of 4

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