20210476 Ver 1_Shoreline Stabilization_20210614

Shoreline Stabilization Application Form
15ANCAC 02H .0500 — Water QualityCertification, Shoreline Stabilization
FORM SSGP 10-2013
DRAFT -NOT FOR USE AT THIS TINE
Submission Form
Pre -Filing Meeting Information
Before submitting this form please ensure you have submitted the Pre -Filing Meeting Request Form as we will not be able
to accept your application without this important first step. The Pre -Filing Meeting Request Form is used in accordance
with 40 C.F.R. Section 121.4(a) "At least 30 days prior to submitting a certification request, the project proponent shall
request a pre -filing meeting with the certifying agency" and in accordance with 40 C.F.R. Section 121.5(b)(7), and (c)(5)
all certification requests shall include documentation that a pre -filing meeting request was submitted to the certifying
authority at least 30 days prior to submitting the certification request. Click here to read more information on when this
form is needed prior to application submission or here to view the form.
Attach documentation of Pre -Filing Meeting Request here:
DWR Pre -Filing Meeting Request Form.pdf 52KB
Pre -fling Meeting or Request Date 3/1/2021
ID# 20210476
I. Applicant Information [15A NCAC 02H .0502(a)]
Version 1
Please note: fields marked with a red asterisk * below are required. You will not be able to submit the form until all
mandatory questions are answered.
Primary Contact Email *
Owner Information:
Name:*
Email:
*
Phone Number:*
Mailing Address:*
[e-mail]
Rease provide an email address for payrrent and requests for pore information here.
Elaine Charlebois
[e-mail]
[phone]
(xxx)xxx-xxxx
Street Address
408 Sycamore Ridge Ln
Address Line 2
CitY
Holly Springs
Rbstal / Zip Code
27540-7959
State / Rovince / Region
NC
Country
US

Is there an agent working on the
project?*
Agent/Consultant Information
Name:*
Company Affiliation:*
Email: *
rr Yes
r No
Shaun Liggett
Concept Contracting and Design LLC
[e-mail]
Phone Number:* [phone]
(xxx)m-
Mailing Address:*
Street Address
301 E. Nash St.
Address Line 2
City State / Province / Region
Louisburg North Carolina
Fbstal / Zip Code Country
27549 United States
Asigned and dated copy of the Agent Authorization letter:*
20210611 Charlebois Waterfront Agent
4.72MB
Form.PDF
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:*
Charlebois Waterfront
If your project has a formal name please use this. If your project does not haw a formal name, please identify your project by
the owner name and proposed activity (Jones Property Access Road, Smith Guest House, etc.) List in parentheses any
other names that haee been used to identify the project in the past.
1. Provide 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.*
(' Upload File
C Look up address
Upload Map: 3325-4.pdf 192.36KB
Latitude:* 35.971147
Longitude:* -78.201989
2. Provide a detailed site plan showing property boundaries and proposed locations of vegetation clearing,
structures (buildings, retaining walls, docks, impervious surfaces, etc.), rip rap, excavation or dredging
below Full Pond/ Normal Water Level elevations, and construction access corridors. You may use the
diagram under section 12.normal pool lake level/normal water level*
20210611_Charlebois Waterfront plan
view.PDF
20210611 Charlebois Waterfront side
view.PDF
20210611 Charlebois Waterfront Site
plan.PDF
6.11MB
7.12MB
7.32MB

Please use the diagram at the link below:
https://edocs.deq.nc.gov/WaterResources/0/edoc/616616/Shoreline%20Layout.docx
3. Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale of some sort- a
yard stick, shovel handle, etc.)*
20210611_Charlebois Waterfront Picture.pdf 5MB
4. Location of the property (where work is to be conducted)
Nearest Town:* bunn
County:* Franklin
Lake/ river/ ocean adjacent to Lake Royale
property:
Subdivisions name or site address:* Lake Royale lot #1332
Include phase/lot number
Directions to site:*
enter at main gate of lake royale on cheyenne drive. take first left at stop
sign onto shawnee drive. take right on oklahoma drive head to sagamore
drive and take left onto sagamore drive lot is located 200 yards on right
side
Rease include road narres and nurrbers, landmarks etc.
5. Describe the existing land use or condition of the site at the time of this application:*
partially cleared and otherwise wooded lot undeveloped
Residential, undeveloped, etc.
6. Property Size 69
7. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
install rip rap along shoreline above nd below normal pool
clear and remove underbrush and small vegetation in order to clear three
large trees in area of new dock
install a 10 x 12 dock over water
install seed straw and new ground cover on disturbed areas.
8. How will the work be done?*
17 From Land
r From Water
9. Total amount of disturbance below the normal pool lake level/ normal water level:*
(including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
130
square feet
10. Total amount of disturbance above the normal pool lake level/ normal water level and 50 feet
land -ward:*
(including all clearing, back fill, excavation, rip rap, retaining walls, etc.)
1000
square feet
11. Please describe the vegetation above the normal pool lake level/ normal water level and 50 feet
landward to be impacted:*

(nunber of trees, for instance)
five large trees and one dead tree
small vegeatations, underbrush and sapplings to be removed
Sketch:
Application Fee:
Once the application has been accepted. You will need to send a corresponding fee in with the appropriate DWR#. The
application fee is as follows (pursuant to G.S. 143-215.3D):
o $240.00 for impacts to lake (below normal water level) of less than 1 acre
o $570.00 for impacts to lake (below normal water level) of greater or equal to 1 acre
By digitally signing below, I certify that:
o I, the project proponent, hereby certifies that all information contained herein is true, accurate, and complete to the
best of my knowledge and belief
o I, the project proponent, hereby requests that the certifying authority review and take action on this CWA 401
certification request within the applicable reasonable period of time.
o I agree that submission of this Shoreline Stabilization online form is a "transaction" subject to Chapter 66, Article 40 of
the NC General Statutes (the "Uniform Electronic Transactions Act");
o I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act");
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the Shoreline Stabilization online form.
Full Name:*
Signature:
Shaun Patrick Liggett
q54.74W ttrra0 ii i`

Initial Review
Is this accepted into the review C' Yes 0 No
process?*
Project Number:* 20210476
Select Reviewer:*
Select Reviewing Office:
Has payment been received?*
What amount is owed?*
Version: *
Stephanie Goss:eads\szgoss
Raleigh Regional Office - [phone]
1
✓ No Payment Needed
✓ Fee Received
C' Need Fee - send electronic notification
C' $240.00
✓ $570.00

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. /332' PLAN NO. PARCEL ID: D 223 5`fi
Pie4 Z`is3 1 -'14- sita to
sat. 6q�aa> . 1.7P-14e—
STREET ADDRESS: 23 �-
Lou 1 S aura -fa Nc--
Please print:
Property Owner:
L-ascEni E. CNkO.Lf., Go/ S
repent 'Owl ef:
The undersigned, registered property owners of the above noted property, do hereby authorize
SDI A v,'1 L (f-k ET —
(Contractor / Agent)
, of Cam 1CF Pr Gr.47,4-Cn.,b 0640 D1E,s'iGN Itc
(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.
Property Owner's Address (if different than property above): i tb)-CfrNIII-Ci/I/0Y 9 �J-n. 7`iC
Telephone: (to9a / ! - a- 62 I q
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
6it'ti2--)r-
Authorized Signature
Date:
Co `-/ O - 0?
Authorized Signature
Date:

REFERENCES: Lot 1332, Lake Royale Subdivision
Deed Book 1941, Page 168
Deed Book 2056, Page 755 — Restrictive Covenants
Map Book 12, Page 35 & 53
Tax Record No. 022359
LEGEND: e . . . found iron as noted
0 . . . set rebar as noted
• property line plotted from record
• easement line
• 100—year flood limit line
NOTE: N.C. Grid station unavailable within 2000' at this time.
NOTE: Area of Lot = 0.437 Acre ( Coordinate Method )
NOTE: This survey is subject to all easements, agreements,
rights —of —way and restrictive covenants recorded prior to
the date of this survey.
NOTE: 100—Year Flood Limit scaled and plotted entirely from FEMA
DFIRM "Franklin County, NC", Map No. 3720283100K,
effective 04/16/13
I, William T. Dement, Jr., certify that this map was drawn under my supervision from an
actual survey made under my supervision (deed description recorded in Book 1941, Page
168); that the boundaries not surveyed are indicated as drawn from information in Map
Book 12, Page 35; that the ratio of precision is 1/20,000; and that this map
meets the requirements of The Standards of Practice for Land Surveying in North Carolina
(21 NCAC 56.1600). This 10th day of April,_ 2017.
(mac
Professional Land Surveyor L-1456
RECORD NORTH
( M.B. 12, P. 35 )
7Se
LAKE
ROYALE
VICINITY MAP
( No Scale )
50' Tar River Basin
Riperian Buffer
100—Year Flood Limits
( See Notes )
\l
Set 5/e" Iran Reb i
w/Top Flush w/
Ground Surface 5'
S of Drain. Ditch 1,
( 1333 )
' Now or Formerly jr
Robert Pringle, et ux, Trs.
( D.B. 1568, P. 498 ) ( '' / /
�-
/'y Found 5/8° Iran Reber " Above ,` ` 1 1� �'j Reber Set /, To n l"
Fo Ground lSurface Near v;,;6�1�'j'\ p,'r ASbrface/
''h S Base of Power Pole �0,009°
�e 1 2a, S 56'36'55"E
''e,>f //e a` 23.135'
?Tie Line From Found P.K. Nail In
Apparent Centerline Intersection
of Sagamore & Stalliion Drives:
S 58'43'15"E 285.93'
/ �Saor
N /
77
eo s
41)
Found 5/8" Iron
w/Top /Top Flush
/Crauntl Surface /J
iR p
SS09 �/
S0�
•
Now or Formerly
Lake Royale P.O.A., Inc.
( D.B. 1803, P. 923 )
( 1331 )
Now or Formerly
Philip Jarres
( D.B. 1708, P. 197 )
Faund 5/8" Iran Reber
w/Top 5 Below
Ground Surface
—LAKE ROYALE—
of Lake
PLAT OF BOUNDARY SURVEY FOR
SABAVIA ENTERPRISES, LLC
(Property Owner — Sabavia Enterprises, LLC)
237 Sagamore Drive, Cypress Creek Township, Franklin County, NC
Scale: 1 "=60'
60 0
Date: April 10, 2017
80 120 180
GRAPHIC SCALE — FEET
Surveyed & Mapped By
WILLIAM T. DEMENT. JR.. Professional Land Surveyor, P.A.
L-1456, C-0649
(0)919-496-6159 (M)919-496-9502
102 West Nash Street Louisburg, N.C. 27549
NOTE: Owners name shown for indexing
purposes only and does not constitute
title certification.
(File No. 3325-4)
ood Sea wall
Found 5/8" Iron Reber
G4° Above
Ground Surface 11 West
of Wood Sea Wall

Water Resources
ENVIRONMENTAL QUALITY
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
Please approximately sketch the following information on this plan and provide dimensions for
each item:
a.
b.
c.
d.
e.
All proposed vegetation clearing
Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
Location of any proposed structures such as buildings, retaining walls, docks, etc.
Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
Lake
(At Full Pond/ Normal Water Level)
Full Pond/ Normal Water Level
Shoreline
2t"rsSDf
fir itze
fo— fvu'
roil o Vol 1-/
Plan View
1Q g P am- 2 Fr x (so 4- 15 lap s f-
2' X Lsc, t- t5+.i2y - Iisf
G e H- x 5� PT
b°p ItlPkGC— •
t( r114
_
Imo'
r-rX 5o Fr
Pic-c.- -- 5 Fe> a--
Wba - arc' —
FORM: SSGP 02-2017
Page 1 of 3

Fr Fr
x
or-1 g" 9ILt,4
Lake
(At Full Pond/ Normal W
I Frkg �au� 2.ff m P1
cV L. f ref Wti j1J 2t., ADOCc+O4N—
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x t vrtr-th l3fpe.
to
Side View
Level)
a (11-,
v
5
c
0
LJ—
Lake
(At Full Pond/ Normal Water Level)
Full Pond/ Normal Water Level
nhore'iine
2 ft. x 150 ft.
additional clearing
• If necessary
Plan View
Existing Dock
30ft x 7 ft
3fta 150ft
Below full pond/ NWL
AM MN as
4 ft x150ft
Above full pond/ NWL
FORM: SSGP 02-2017
Page 2 of 3

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DWR Pre -Filing Meeting Request Form
ID#*
Regional Office *
Reviewer List*
20210476
Version*
1
Raleigh Regional Office - [phone]
Stephanie Goss
Pre -Filing Meeting Request submitted 3/1/2021
Contact Name * shaun liggett
Contact Email Address* [e-mail]
Project Name * Charlebois Waterfront
Project Owner* Elaine Charlebois
Project County* Franklin
Owner Address: Street Address
156 highstone street
Address Line 2
City State / Rovince / Region
EastTaunton MA
Fbstal / Zip Code Country
02718 United States
Is this a transportation project?* C Yes ( No
Type(s) of approval sought from the DWR:
rJ 401 Water Quality Certification - I— 401 Water Quality Certification -
Reg ula r Express
I— Individual Permit I— Modification
rJ Shoreline Stabilization
Does this project have an existing project ID#?*
C Yes ( No
Do you know the name of the staff member you would like to request a meeting with?
stephanie goss
Please give a brief project description below.*
shoreline stabilization and dig boat slip install 10x10 dock over water
Please give a couple of dates you are available for a meeting.
3/5/2021

3/8/2021
Please attach the documentation you would like to have the meeting about.
20210301_237 sag_ncdwr sketch.PDF 6.39MB
pdf only
By digitally signing below, I certify that I have read and understood that per the Federal Clean Water Act Section
401 Certification Rule the following statements:
• This form completes the requirement of the Pre -Filing Meeting Request in the Clean Water Act Section 401 Certification
Rule.
• I understand by signing this form that I cannot submit my application until 30 calendar days after this pre -filing
meeting request.
• !also understand that DWR is not required to respond or grant the meeting request.
Your project's thirty -day clock started upon receipt of this application. You will receive notification regarding meeting location
and time if a meeting is necessary. You will receive notification when the thirty -day clock has expired, and you can submit an
application.
Signature
reec fzwele 6li
Submittal Date 3/1/2021