20191071 Ver 1_Shoreline Stabilization_20190809

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State of North Carolina
Departmertie*'E,il�vironment and Natural Resources
e, Division of Water Resources
Water Resources 15A NCAC 021-1 .0500 — Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL QUALITY FORM: SSGP 02-2017
Shoreline Stabilization Application Form 2 0 1 9 1 p 7
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)]�� a \0\
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1. Owner Information c6x
Name: R.4
Mailing Address: 5:2_3 I-4 !L_1_Woo D C0(4#(2_-r-
67
OGt/27—
67A�EEA/-TL30i20 , /VC , 1-74/ o
Telephone Number: 3�6 -R7 9 - 4 8 7 `/ Fax Number: IVOA%E
E-mail Address: f -Ce rr l.S g 2-2 C q cki l C o 14A
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:
htto://www.saw.usace.armv.mil/Portals/59/docs/reeulatory/reRdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
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 CCASWrit CO,
respect to local landmarks such as towns, rivers, and roads.
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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.) 5;e-:A17T % 5rAF/�AIAIVIC G'oTS
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4. Location of the property (where work is to be conducted)
County: Nearest Town:
Lake/ river/ ocean adjacent to property:
Property size (acres): . gjt�_
Subdivision name or site address (include phase/lot number): R77;4C�-joif',o
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Directions to site - please include road names and numbers, landmarks, etc.:
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Latitude (in decimal degrees) Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Ri551 MAI LI A 4,
Describe proposed work (include discussion as to how hardening of shoreline has been
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avoided, or why it is necessary): /C
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7. Will work be conducted from land? � 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:
-7-6-0
Temporary impacts in s uare feet:
A10045
9. Total amount of impacts above the normal pool lake level/ Normal Water Level and 50 feet
land -ward /VOMV
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
Temporary impacts (temporary clearing, construction corridor) in square feet:
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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):
11. Signature��� � �✓G����
Owners/Agent's Signature' [1SA NCAC 02H .OS02(f)]
-9-7 19
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/
Plan
Lake
(At Full Pond/ Normal Water Level)
Lake
IM PW P6,41 N—I W.u` L-11 Existing Dock
/ 40"A 7 M
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Plan View
FORM: SSGP 02-2017 Page 3 of 4

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Side View
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10 ft. bank
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Side View
3 h. below full pond water level 4 ft, above full pond water level 2 h. additional clearing
if necessary
Existing bank
AMPLE
FORM: SSGP 02-2017 Page 4 of 4

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Richard & Joanne Ferris
81 Hyco Hills
Property o; Norman Hubert Bedell
& Doretha L. Bedell
Plat Book 10, Page 581
Milton Township
Caswell Township
Caswell County, N.C.
Tax Parcel: 0125.01.00.0002
Deed Book 311, Page 465