20190672 Ver 1_Shoreline Stabilization_20190520

State of North Carolina
$_Fr%!Ment of Environment and Natural Resources
lira. 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
20190672
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 ["�5A NCAC 02H .0502(a)]
1. Owner Information
Name: G �/
Mailing Address: U
Telephone Number: ,22�/ Fax Number.
E-mail Address:>�/Y�Y/Grt�✓Y��../,
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/`reedocs/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 property (where work is to be conducted)
County: Nearest Town: it/O%l.cJOod—
Lake/ river/ ocean ad' cent to properly: i
Property size (acres): qZ11
lz j
Subdivision name or site address (inclyde phase/lot number): T�
Directions to site - please include road na es and numbers; landmarks, etc.:
^ e
Latitude (in decimal degrees) Longitude (decimal degreesJ—��4'y
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): kp:5 -,e
6. Describe proposed work (include
avoided, or why it is necessary):
7. Will work be conducted from land? Jam,
is to how hardening of shore/line has
A-/ -A /?
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:
in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanente
back fill, excavation, rip rap, retaining walls, etc.) in square feet:
Temporary impacU (temporary clearing, construction corridor) in square feet:
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): /Allea, A6
I--- _ , ., , If 11
11. Signature
Owner/Agent's Signature f 15A NCAC 02H .0502(f)l D to
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 of 4

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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
La ke
(At Full Pond/ Normal Water Level)
Full Pond/ Normal water Level
Am 0" Alm
Shoreline
Plan View
FORM: SSGP 02-2017
Lake
Uu rctd/ Notmaf Water tr.N) Existing Dock
3U ft. ft
3hxjMit
faebni�M�dl NINL
Full Pond/ Normal Water Level — — — INS
Shoreline Riprap obo=e fte paW f>fwt
2 h.=150 ft.
additional deanng
If necessary
c-,. AMPLE
Plan View
Page 3 of 4

Side View
U-
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 a
height OyO
r�
no
ice' - I
�W►
NMI=rs ,m 0109
FORM: SSGP 02-2017
Page 4 of 4

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