20191228 Ver 1_Shoreline Stabilization_20190916

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
P1 IV
LOT NO. PLAN NO.PIM ID:
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STREET ADDRESS: '? q)
Please print:
Property Owner: N, (ci LLf11 V
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Property Owner:
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The undersigned, registered property owners of the above noted property, do hereby authorize
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(Contractor / Agent) (Name 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,
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Property Owner's Address (if different than prop" above): VA z2z u-1
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Telephone:
We hereby certify the above Information submitted In this application Is true and accurate to the
best of our knowledge.
Authorinature Autho�,�Signature
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Date: Date: Z�
*R-
F. P 1 2019
40
Regional Operations Section

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
1SA NCAC 02H .OS00 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 02-2017
Shoreline Stabilization Application Form
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)]
1. Owner Information
Name:
Mailing Address:
2Z -2-V1
Telephone Number: 70'�- 33), • Lg7Fax Number:
E-mail Address:
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:
littp://www.saw.usace.il Port�5yjdocs/regulatory%reRdocs Permits/SAMPLE _AGENT AUTHORIZ
ATION FORM.pdf) I 7
Name:
Company Affiliation:
Mailing Address:
Telephone Number: 911
E-mail Address:
Fax Number:
B. Project Information [15A NCAC 02H_ 0502(At&. (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 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.)
4. Location of the property (wre work is to be conducted)
County: 41 I -]
i Nearest Town: y1
Lake/ river/ ocean adjacent to property:
Property size (acres): _ 3�� tf(. /e
Subdivisionname or rite address (include phase/lot number): _
Directions to site -plea7s! 'nclu�ie r%nam� nd um ers,1Pdmar s, etc.
inn n lk a— ,�c,'1 I(.,,,. n
Latitude (in decimal degrees)
Longitude (decimdl degrees) v
5. Describe the existing land use or condition of the site t th ti of this application
(residential, undeveloped, etc.):,1
6. Describe proposed work (include discussion as to hoNv har�enjg of s or linXa;M ,ljavoided, or why it is necessary): U11 exp iNu Y" ,t
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 (inclildineall a cavation, backfill, rip rap, t fining walls, tc. in square feet:
L�l (i i 7 i
Temporary impacts in square feet:
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9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including "„ exc ` 'op, rip rap, ret�alls, etc.) 'Pjquare feet:
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Temporary impacts (temporary clearing, construction corridor) in square fed:
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50
feet landward to be impacted (numbgr If trees, for instance):
11. Signature
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Owner/Agent's Signature* [15A NCAC 02H .0502 f
Date
Agent's signature is valid only if on 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 Level
=111Shoreline
Plan View
Fuli Pond/ Normal Water L
hore
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Z h.r 15011.
. addtiaW ckr6.6
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Lake
(At Full Pond/ Normal Water Level)
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Lake
(At F4 F,4zl N --I Weer L-1)
Existing Dock
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EXAM P E
Plan View )
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FORM: SSGP 02-2017 Page 3 of 4

4o-OL.6m,W 1(4f
3 ft. below full pond water level 4 ft. above full pond water levt l 2 ft. additional clearing
'if necessary 1
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Existing bank
10 ft. bank
height
Side Vi
AMPLE
FORM: SSCP 02-2017 Page 4 of 4

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