20191039 Ver 1_Shoreline Stabilization_20190801

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State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .05t'Wo Quality Certification, Shoreline Stabilization
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FORM: SSGP 02-2017
Shoreline Stabilization Application Form 1 9 1 0 3
9
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 [15A NCAC 02H .0502(a)]
1. Owner Information
Name:
Mailing Address:
Telephone Number:,77�
E-mail Address:
2. Agent/ Contact Person Information
Fax Numbers !F3 +/S__
A signed and dated copy of the Agent Authorization letter must be attached if the Agent has
signed this application form. (Aform can be downloaded here:
httD://www.saw.usace.armv.miI/Portals/59/docs/reRuIatory/re2docs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name: P
Company Affiliation: C - e
Mailing Address: L2 12, S
Telephone Number:o1,5 ; - - Fax Number:
E-mail Address: 1 j- o SAP k- /7 % 7?raaQ r
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: SSGP02-2017 Page 1 of 3

3. Attach a photograph of the shoreline/ buffer proposed to(Include a scale of
S�P�some sort- a yard stick, shovel handle, etc.) Aa sta ilized.
4. Location of the property ()where work is to be conducted)
County: f �LL 1�l K l / yl, Nearest Town:
Lake/ river/ ocean adjacent to property: La, P,
Property size (acres): S
Subdivision name or site address (include phase/lot number): o
Directions to site - please include rod aures and nu be s, landmarks, etc.:
J
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Ckey!h he
Latitude (in decimal degrees) Longitude (decimal degrees)
.Dr,
Describe the existing land use or condition oft the site tth time of this application
Pte,
(residential, undeveloped, etc.): r�S%
6. Describe proposed work (include discussion, s to how hardening o horeli a has een
avoided, or why it is necessary): LL
7. Will work be conducted from land?Rr From water?❑
8. Total amount of impacts below the normal pool lake level/ Normal Water Level
Permanent impacts (including
Temporary impactsin square feet:
backfill, rip rap, retaining walls, etc.) in square feet:
9. Total amount of impactsabove 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:
10. Please describe the vegetation above the normal pool lake level/ Normal Water Levelan 50
feet landward to be impacted (number of trees, for instance): SSAdn
/ JL --
11. Signatur
a
Owne Agent's nature [15A NCAC 02H .0502(f)] Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP02-2017 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
Full Pond/ Normal Water Level
Shoreline
FORM: SSGP02-2017
Full Pond/ Normal Water
2 ft. M 150 ft.
additional clearin
if necessary
La ke
(At Full Pond/ Normal Water Level)
Se 2
Lake
(At Full Pond/ Normal Water Level) Existing Dock
/30 ft K 7 f
E
E
Page 3 of 4

3 ft. below full pond water level 4 ft. above full pond water level 2 ft. ad
Existing bank
10 ft. bank a
height O�Q'
OQ
-CiA-fX A IN MPL
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FORM: SSGP02-2017 Page 4 of 4
J
Lake
(At Full Pond/ Normal Water Level)
C
E
L-
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o
3 ft. below full pond water level 4 ft. above full pond water level 2 ft. ad
Existing bank
10 ft. bank a
height O�Q'
OQ
-CiA-fX A IN MPL
Q�
FORM: SSGP02-2017 Page 4 of 4

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