20191051 Ver 1_Shoreline Stabilization_20190806

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State of North Carolina
IN
Department of Environment and Natural ResourcesDivision of Water Resources
15A NCAC 02H .0500 - Water Quality Certification, Shoreline Stabilization
FORM: SSGP 02-2017
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Shoreline Stabilization A; orm 1 0 1 9' 0
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Three copies of the application (including attachments) and the application fee should be sent to:
If sending via US Postal Service
Karen Higgins
DWR — 401 & Buffer Permitting Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
If sending via delivery service (UPS, FedEx,. etc.)
Karen Higgins
DWR — 401 & Buffer Permitting Branch
512 N. Salisbury Street
Raleigh, NC 27604 \ 11 1% I'"
A. Applicant Information l 1 5A NCAC 02H .0502(a)1
1. Owner Information
Name: t '()z_
Mailing Address:
Telephone Number:
E-mail Address:
e��rICAQ_ NC Q&D-76
2. Agent/ Contact Person Information
Fax Number:
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:
httn.//% rmw sawn usace army mil/Por-ais/59/docs/reg,,.ia�cp,/regdocs/Permits/SArliPLE 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 I 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: f �'
Lake/ river/ ocean adja to property: +W -O
Property size (acres):\ 3Q c��
Subdivision name or site address (include phase/lot number): t--77�A;e -
Directions tosite - please include road names a nu ers, landmarks, etc.:
Latitude (in decimal degrees) Sv� %�y Longitude (decimal degrees)
5. Describe the existing land use or condition of the a pt the dime of this application
(residential, undeveloped, etc.):
6. Describe proposed work (include discussion as �q how hardeninZ of shoreline
avoided,or by�# is necessary):
7. Will work be conducted from land? From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanentacts (inching all excavation, ba II, rip rap, retaining walls, etc.) in square feet:
Temporary impacts in s uafe feet:
9. Total amount of impacts above the normal pool lake level/ Normal Water Level and 50 feet
land -ward
it impacts (including back fill, excava!' n, rip rap, retaining walls, etc.) in square feet:
/��'
Temporary
construction corridor) in square feet:
10. Please describe the vegetation above the normal pool lake level/ Normal Water level
feet landWdrd to be impacted (number of trrees, for
11. Signature
Co - 1
Owner/Agent's Signature [15A NCAC 02H .0502MI 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
Full Pond/ Normal Water
Shoreline
Plan View
FORM: SSGP 02-2017
Lake
(At Full Pond/ Normal Water Level)
Lake
tkr,APQWwmiwmvk+dl Existing Dock
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Page 3 of 4
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Lake
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Side View
10 ft. bank
Side Vi
FORM: SSGP 02-2017
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3 ft, below full pond water level 4 ft. above full pond water level 2 ft. additional clearing
If necessary
Existing bank
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AMPLE
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