20191217 Ver 1_Shoreline Stabilization_20190913

State of rthRA J
Department of Environment and Nat r esources
Division of Water Resour
Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL OUALI 1 v FORM: SSGP 02-2017
Shoreline Stabilization Application Form 2 C 1 9 1 2 1 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, INC 27604 QRi
A. Applicant Information [15A NCAC Q2H .0502(a)�6
1. Owner Information res
Name: c'Sar.e.
Mailing Address: c9aq tj. &t*- Core, ej ��►'"�g
Sem MC 2-73143
Telephone Number: 3134 y5y &2&! Fax Number:
E-mail Address: J PI-mdrY(2� A044uhx ne_4
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://www.saw.usace.army.
mil/Portals/59/docs/reaulatory/readocs/Permits/SAMPLE AGENT AUTHORIZATION FORM.odf)
Name: 'J_0 ( W I ku5n,
Company Affiliation: rriot kkA rS� 01AHi6'r
Mailing Address: Lit y Il -(-� t{.w y
SoUA-h '8osfan YFr aki "Z'
Telephone Number: 43q 5-79 5416" Fax Number:
E-mail Address: Jcq Q Vv%.fI'Lk&J'*a6_4-Js,a I-v;"*3,csw,
B. Project Information [15A NCAC 02H .0502(a) & (b)l
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.
V2. 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.)
FORM: SSGP 02-2017 Page 1 of 3

4. Location of the property (where work is to be conducted)
County: ?U56 -on Nearest Town: Rex4er• I'NL
Lake/ river/ ocean adjacent to property: iAkA-
Property size (acres): IL06L
Subdivision name or site address (include phase/lot number):
a,9C4 N. Oak Cevc Dr &.VWC-- 1UG. .273{3
Directions to site - please include road names and numbers, landmarks, etc.:
Mr-E►htes 11x1;11 �,� TUrII �.A6 DALR;-& Dr, e,a-• DAL p lu 1),
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.): ICL4A`c144
6. Describe proposed work (include discussion as to how hardening of shoreline has been avoided
,or why it is necessary): Z'rpsrer, -be{, � '�►'^1 �S P �a.P L^" h-- -tD .W fu -t
OF shun 1: �.A / tAA t-6 ";I
7. Will work be conducted from land? From water?
8. Total amount of impacts below the normal pool lake level / Normal Water Level 7 j
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
1 00 -Ptz do IntA -qvt loo` tgnq x -tw
Temporary impacts in square feet:
2Cb6 4�I- L d. t -ci Irr CJK0JAI
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:
200 �Pt` X471A '&u. Z 1 ou' t aK.\ x -\-' akm -RAI ooe 1
Temporary impacts (temporary clearing, construction corridor) in square feet:
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. Signatur
Owner/Agent's Signature* (15A NCAC 02H .0502(f)] 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 dimensions for
each item:
FORM: SSGP 02-2017 Page 2 of 4

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
Lake
(At Full Pond/ Normal Water Level)
�A 0
Full Pond/ Normal Water Level'"
Shoreline �;l_o� $o,
v 'VILA
Plan View
FORM: SSGP 02-2017 Page 3 of 4

Side View
LL
101
K
Lake
(At full Pond/ Normal Water L"l) Existing Dock
/30Rc7lt
EXAM P E
Plan View
Side View
FORM: SSGP 02-2017
h. additional clearing
"if necessary
Page 4 of 4
ar
rq}
Mrs,
ad �Iit,!OnM clearing
EXAM P E
Plan View
Side View
FORM: SSGP 02-2017
h. additional clearing
"if necessary
Page 4 of 4

5P A I . aj

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO.
STREET ADDRESS:
Please print:
Property Owner:
Property Owner:
J99 41 Afor4t
PARCEL ID: 96fO ^ °f_ I11=A5y4.0%&
©e-aVxDr
Soft -w -x N c. a r314 3
V"t
The undersigned, registered property owners of the above noted property, do hereby authorize
(Contractor / Agent) --(Namf of consulting 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):
51 l 0 n& l I- Ja wi tFewn _ Pic 2e?Zf 2
Telephone: 93�.
14N cap -0
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
A orized Signatur-o"
Date: — QLS/-----------
TWLA-C.,f V � t-Arrr --
Authorized Signature
Date:

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