20191097 Ver 1_Shoreline Stabilization_20190815

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 —Water Quality Certification, Shoreline Stabilization
FORM: SSGP 02-2017
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fec should be sent to:
If sending via US Postal Service If sending vin delivery service (UPS, FedEx, etc.)
Karen Higgins Karen Higgins
D WR — 401 & Buffer Permitting Branch D WR — 401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information 115A NCAC 02H.0502( j
Owner Information
Name: Wa r X g J e y
Mailing Address:
933q--P1or`rmoa y
ilentle, A/C R�J %
Telephone Number: 7 -
`70 - 5Fax Number:
S�"/ �oSo3
E-mail Address: 44a ry r 1.5 l S' �
ke1l5aw A67 . 17 e-�
20191097
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://wwcv.saw.usace.arrny.miUPortals/59/docs/regulatory/regdocs/Pertnits/SAMPLE AGENT AUTHORIZA
TION FORM.odtl
Name: 'Terry 44OY'y17W
Company Affiliation:
fill
Mailing Address: 5-0 c/an� j GY iL w ✓`
114f u flu
Telephone Number: Fax Number. ;1O
w�- 73? -305-0
E-mail Address:
,rnorrrOcL' &J 49(1Wr4erW­Y.5 C0175�, COPY?
B. Project Information It 5A NCAC 02H .0502(g
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.
https://files.nc.gov/ncdeq/Water%20Quality/Surface%2OWater%...d%20Permits/SSGP%2002-2017%2OShorelir.e%2OForm_final.docx 7/21/19, 4:35 PM
Paoe 1 of _c,

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.
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: L) n Co in Nearest Town:
Lake/ river/ ocean adjacent to property: LjleZ /Z/Grlrltr✓!
Property size (acres): s 25— Ll6 t -e }
Subdivision name or site address (include phase/lot number):
6331(- ,21�1111r, an dy �16111.1
Directions to/ site - please include road names and numbers, landmarks, Lete.:
c-7 4ci �,f h r �y � Al w eL 7u- en
on 4C' /r/o,�mk4,11 )fid bvee>k f s crba'ca f a mile awn O -/ le -V
Latitude (in decimal degrees)_ '"1h Longitude (decfmal
degrees) 3 T. Y -7s7/ 5''
5. Describe the existing land use or condition of the site at the time of this application (residential,
undeveloped, etc.): j�e5 r ery T r H !' [` c f w/ �4 jl o u e
6. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
-L ke�novigj exl5hKs W1111 builjfr i$
j 'erne --typiL rc�ull
1.4 7Ae 5amc ptae-.
%. Will work be conducted from land? From water?
wJOrle- wrff he rtr" lciac(
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:
rl�rNp :3` X 2UUf�GDsf.�-�
Temporary impacts in square feet.
rx 5'G' yov s� �f '9C4 -fe) s hvvc fill t
a X Z Ott U jGns Shire l N e �OG 5� 14 d e-
9. Total amount of impacts above 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:
ZaO S� 10(
3 ` V'tA-N f a1( w- !!
2` � hefty wit �(
https://flies.nc.gov/ncdeq/Water%20QuaIity/Surface%20Water%...d%20Permits/SSGP % 2002-2017%20Shoreline% 20Form_final.docx 7/21/19, 4:35 PM
Page 2 of 5

Temporary impacts (temporary clearing, construction corridor) in square feet:
10',r 5`V 52�0 sip
/0',X 2X geVO 5clP al",S . {tGre /r rr e
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): ' n t rNJ I runes e-� 4- 4re e s
5 M 5 7 !f -fee--s 3o' b a fr
c ,,a SLOK
11. Signature / / / 7'
7y`,
Owner/Agent's Signature f 15A NCAC 02 .0502(fll Date
Agent's signature is valid only if an authorization letter
from the owner is provided.
12. Please approximately sketch the following information on this plan and provide di» aesions for
eack 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
0 � � �
Shoreline
Plan View
La ke
(At Full Pond/ Normal Water Level)
GC L
e
f
3--- 3 Z'
https://files.nc.gov/ncdeq/Water%20Quality/Surface%20Water%...d%20Permits/SSGP%2002-2017%20Shoreline%20Form_final.docx 7/21/19, 4:35 PM
Page 3 of 5

Lake
M 10 ibq/-- W— Levef/
Existing Dock
bh�)h
3hnI50h
.....' lMar ha poM/vWt
Full Fond/ Normal Water Lavd ,
RiWaD -'- - . •eoe lW aawtwq
1h .IWh +
Watbn�l<kxirr`
.t necnW
E AMP E
Plan View
Oat r a 4-a WC, C
r0`10
4d Ton of
Lake
(At Full Pond/ Normal Water Level)
Side View
v
J
i0
E
0
z
C
0
u -
i JIAf 0/011
3 ftbelow fun Fond water lerel 4 ft. above full pond water level 2 ft. additional clearing
'M necessary
Existing bank
10 ft. bank a
height Dye
I r6
�r +'V-WJ
https://files.nc.gov/ncdeq/Water%20QuaIity/Surface%20Water%...d%20Permits/SSGP%2002-2017%20ShoreIine%20Form_final.docx 7/21/19, 4:35 PM
Page 4 of 5

MAP
IV -±f —
1' JO S EV sr•
sEUJM
os—s+s
L.
I.S.= IRON SET
I.F.- IRON FOUND
PH `-FArCAZ .S UA"? YE Y OF
LOTO 9,D ,Q,k 44 DL3314 11 & A PdrtTlply yr L_v I ) I IN
BLOCK C OF SHADY GROVE PARK
PROPERTY OF MARY RILEY
SCALE: '1 *=50' DENVER, LINCOLN CO., N.C. DATE: APR. 08, 2002
AS Rg94RDED IN MAP 130811 G PC 44 Baa ,v,v
8334 NORMANDY ROAD

Big Oak Farm V.,
paykox,� ., .�►
:r -
ake lettering and design
Unit c vr�ty
Y h urch Rd
Vandaiay Dr`=, '
3 Cherry-
*5-
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acier Drive �a
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