20191248 Ver 1_Shoreline Stabilization_20190917

Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center 2 0 1 g 1 2 4 8 REC�'JEUDENRIDW
Raleigh, NC 27699-1617 SEP 17 2019
Water Resources
I. Applicant Information [15A NCAC 02H .0502(a)] Permii3ng Section
1. Owner Information /
Name: -` t orme,s' A fie'c- t1` et
Mailing Address: 3 3 L4 Y (3 y-ecks dc? o
` ✓Yl i7 �� e; �w�
4&
Telephone Number: �g�Lf. LtO7 lyc(r Fax Number:
E-mail Address: m ru s Lu c -c -k fev (� .v%cx" 1. c ci s
2. 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 rail/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Person to receive the Certification Approval:
II. 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: 41,eY cco7 deG, - Nearest Town:
Subdivision name or site address (include phase/lot number):
Directions I1»")e'to site - please include road names and numbers, landmarks, etc.: /'V 0r°I(K1'
OL -7, Pt1'7'Jeje_,46-yi L cya_ � JO 01' 'SLI iU, t, Vyi Ly'i( 1A,
�t ��=S.S �- Uv► � �tri�.-4t:�'�i L.�v�A : L= Cavi j�.lG�•�l�l S'��r'�_ I� v�'i
Latitude (in decimal degrees) 35 S 0SY. j y Longitude (decimal degrees) 0 . 3 -3
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): 1c:e,& i Aevv-Ai z (
6. Property size (acres):. 7 a rc-
7. Lake/ river/ ocean adjacent to property: t-,Cx ke, or+-/
S. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
9. Will work be conducted from land? �Z From water? ❑
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:. 0 _Y!,U436,�e P -e-,4---
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 r"
Owner/Agent's Signature* [15A NCAC 02H .0502
2->9
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 Mater Level
W" . E
Shoreline
4
Lake
(At Full Pond/Normal Water Level)
01-oad
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

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