20191142 Ver 1_Shoreline Stabilization_20190826

State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Reso
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabllization 1®
Division of Water Resources
FORM: SSGP 10-201r"___1
Shoreline Stabilization Application Form 2 0 1 9 1 1 42
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
S
1617 Mail Service Center���w
Raleigh, NC 27699-1617
I. Applicant Information 15A NCAC 02H .0502(a)]
1. Owner Information
Name:
Mailing
Telephone Number: 70`/-S �%��`i Fax Number:
E-mail Address: %A CC"0 (i 1401. c �• G '�
Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http://www.saw.usace.army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached
. if the Agent has signed this application form.
Name: 81a.-1d�, r' l C L1✓pSC-1—_
Company Affiliation: /r. or -�� ` % s f u C -t-_
Mailing Address:
1-4 �� G�/, � . s
Telephone Number: 003-531- ,�-3%w Fax Number:
E-mail Address:
Person to receive the Certification Approval:��.
11. 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, structures (buildings, retaining walls, docks, impervious surfaces,
FORM: SSGP 10-2013 Page 1 of 3

etc.), 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: Nearest Town: 1_'11 r�oft�
Subdivision name or site address (include phase/lot number): Lof
95'3 / /1,. ,��euL VQQ . C kr loge, , AIZ _.?ZZ79"�
Directions to site - please include road names and numbers, landmarks, etc.:
IC,
Latitude (in decimal degrees) 35; OS_3 2,00 Longitude (decimal degrees): d tid1 %d
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Tes�c�e+t f�a
6. Property size (acres): ZI02 aCc�S
7. Lake/ river/ ocean adjacent to property:
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): tc o i vuS tie L a lwic 4-,4 mmr,_'- &Iatiuc
k/C GWrI�( 1� C{ytyyrtei�
9. Will work be conducted from land? & From wated ❑ She rti It", e
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake level/ Normal Water Level in square feet or acres:
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres: �, 76a s��i,
12. 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): /1? 4-1`�c- rated t o �-e_
r AJC__
�o f a ccek5 Or,- Ra,4 o Pro p.�rn 300 CF ro�u� ; s yyros-�1�� 9 FasS,
Scc�l.� S-{-fau/ a-�. � ut'G� a l � O�i s-t�b�-- a�',cc�s l,✓�� C�rl�t�,
r genfs Signature* [15A NCAC 02H .0502(f)] Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Full Pond/
Normal Water Level
SI
Lake
(At Full Pond/ Normal Water Level)
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft)*:
1. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
3. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
4. Location of any proposed structures such as buildings, retaining walls, docks, etc.
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corridors
FORM: SSGP 10-2013 Page 3 of 3

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO.
PARCEL ID: .:2 I %3 11 % / 0
STREET ADDRESS: /,,'l►�u�C
Please print:
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
-%M3 -11 - V Ic of 2 e"' Zt & 9—�
(Contractor / Agent)-- 3 (Name of co sultin firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
Telephone:
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
/, /,�&)4/v 4,,
Authorized Signature
Date: 0 -(q
uthorizedSignature
C
Date: O ',2�

7/20/2019 3990 Charlotte Hwy, Clover, SC 29710-8083 to 19531 Bankhead Rd, Charlotte, NC, 28278-8565 Directions - MapQuest
r Y 6UR TRIP TO: mczxz�
19531 Bankhead Rd, Charlotte, NC, 28278-8565
13 MIN 1 6.4 MI R
Est. fuel cost: $0.63
Trip time based on traffic conditions as of 11:10 AM on July 20, �9Print a full health report of your car with HUM
2019. Current Traffic: Light vehicle diagnostics [phone]
4 1. Start out going northwest on Charlotte Hwy/SC-49 toward Blucher Cir.
VJ
Then 0.05 miles 0.05 total miles
^ 2. Make a U-turn at Blucher Cir onto Charlotte Hwy/SC-49 (Crossing into North
•�,I Carolina).
If you reach Executive Ct you've gone about 0.2 miles too far.
Then 0.39 miles 0.44 total miles
T 3. Charlotte Hwy/SC-49 becomes York Rd/NC-49.
Then 0.85 miles 1.29 total miles
r+ 4. Turn right onto Grand Palisades Pkwy.
Grand Palisades Pkwy is 0.4 miles past Red Fez Club Rd.
If you are on S Tryon St and reach Langston Dr you've gone about 0.1 miles too far.
Then 1.95 miles 3.24 total miles
5. Enter next roundabout and take the 3rd exit onto Youngblood Rd.
Then 0.63 miles 3.87 total miles
r* 6. Turn right onto Mckee Rd.
If you reach Rhone Valley Dr you've gone about 0.1 miles too far.
Then 1.27 miles 5.13 total miles
T 7. Stay straight to go onto Bankhead Rd.
Then 1.02 miles 6.16 total miles
I+ 8. Turn right to stay on Bankhead Rd.
Bankhead Rd is just past Wilbanks Dr.
If you reach the end of Tayport Dr you've gone about 0.1 miles too far.
Then 0.21 miles 6.37 total miles
https://www.mapquest.com/directionsllist/1/us/sc/clover/29710-8083/3990-charlotte-hwy-35.106658,-81.041425/tolus/nc/chadotte/28278-8565/19531-... 1/2

7/20/2019 3990 Charlotte Hwy, Clover, SC 29710-8083 to 19531 Bankhead Rd, Charlotte, NC, 28278-8565 Directions - MapQuest
9. 19531 Bankhead Rd, Charlotte, NC 28278-8565, 19531 BANKHEAD RD is on
the left.
s `Your destination is just past Variety Ln.
Your destination is at the end of Bankhead Rd.
M Save to My Maps
Use of directions and maps is subject to our Terms of Use. We don't guarantee accuracy, route conditions or usability. You assume all risk of use.
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