20190547 Ver 1_Shoreline Stabilization_20190424

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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: r L� r. t , ,tip_ Nearest Town:
Lake/ river/ ocean adjacent to property:
Property size (acres):
Subdivision name or site address (include phase/lot number): n to ^L
I+ta , I
Directions to site - please include road names and numbers, landmarks, etc.:
Latitude (in decimal degrees) 3,5,'!-;16 y 4 ;, �) Longitude (decimal degrees)
Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): f' >''^1i 21" 'lr► 12�,1c1 1p. �ot
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): % r A i,;, -- J ' r i I
7. Will work be conducted from land? V 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:
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and SO feet
land -ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
L4 '
Temporary impacts (temporary clearing, construction corridor) in square feet:
', Cc) _ -1 . t'-"
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and SO
feet landward to be impacted (number of trees, for instance):
✓rr--`�' '- f T tf,JI• �y�. f �Jr
11. SigryljXuS

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO, PARCEL ID:
Please print: I
Property Owner: l ( C U1 \
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
co r 1 G'V of
(Contractor / Agent) (Name o consulting firm)
NO bblflsu Ae)-
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: z4oq — 13 -� �re( f Kvv
170-59-+- Woo - 61' h 1 r�yVkahl
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
V
Authorized
Date: We

Water Resources
LNVIRONMLNIAL UUr,.,...
2 0 1 90 5 47
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
ISA NCAC 02H .0500 — Water Quality Certification, Shoreline StaWlization
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, 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 [t5A NCAC 02H .0502 a )
1. Owner Information
Name:
Mailing Address:
Telephone Number:
E-mail Address:
�q�c'��kl1`1
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/regulatory/rtg ocs/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) & bl]
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.