20211151 Ver 1_Shoreline Stabilization_20210726

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 viewthe form.
Attach documentation of Pre -Filing Meeting Request here:
DWR Pre -Filing Meeting Request Form.pdf 50.66KB
Pre -fling Meeting or Request Date 7/28/2021
ID# Version
I. Applicant Information [15A NCAC 02H .0502(a)]
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 * [e-mail]
Rease provide an err -ail address for payrrent and requests for pure infornation here.
Owner Information:
Name: * william royal
Email: * [e-mail]
Phone Number:* [phone]
(xxx)xxx-xxxx
Mailing Address:* Street Address
315 pebble beach drive
Address Line 2
City
State / Frovince / Region
mebane
NC
Fbstal / Zip Code
Country
27302
United States

Is there an agent working on the f Yes
project?* r No
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:* Royal Lake House
If your project has a formal name please use this. If your project does not have 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 have 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.
r Upload File
r Lookup address
Property Address Lookup:* Street Address
32 Peninsula Drive
Address Line 2
Latitude:* 36.455461
City State / Province / Fbgion
Roxboro NC
Fbstal / Zip Code Country
27574 United States
Longitude:*-79.080303
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*
Royal Lake House Shoreline Stabilization.pdf 4.55MB
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.)*
Royal Lake House Shoreline Stabilization.pdf 4.55MB
4. Location of the property (where work is to be conducted)
Nearest Town:* Roxboro
County:* Person
Lake/ river/ ocean adjacent to Hyco Lake
property:
Subdivisions name or site address:* Qual Hollow, section 4, phase 1, lot 27
Include phase/lot nunber
Directions to site:*
from Roxboro, take highway 57N approximately 6 miles to concord
church road, turn left. go approximately .8 mile turn right on Quail
Hollow Drive. go approximately .4 miles turn right on summer oak,
proceed peninsula place vacant lot on right, #27
Rease include road narres and nunbers, Iandnarks etc.

5. Describe the existing land use or condition of the site at the time of this application:*
residential/undeveloped/wooded lot
Residential, undeveloped, etc.
6. Property Size 4.29 acres
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
Install rip rap starting at water usage mark and extending 105 feet to
avoid erosion along shoreline
8. How will the work be done?* V From Land
r From Water
9. Total amount of disturbance below the normal pool lake level/ normal water level:*
(including all clearing, backfill, excavation, rip rap, retaining walls, etc.)
160
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.)
160
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)
no trees on shoreline where rip rap will be placed
Sketch: Royal Lake House Shoreline Stabihzation.pdf 4.55M13
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):
0 $240.00 for impacts to lake (below normal water level) of less than 1 acre
0 $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');
0 1 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:* william royal
Signature:

Initial Review
Is this accepted into the review
process?*
Project Number:* 20211151
Select Reviewer:*
Select Reviewing Office
Has payment been received?*
What amount is owed?*
rYes allo
Version:* 1
Stephanie Goss:eads\szgoss
Raleigh Regional Office - [phone]
r No Payment Needed
r Fee Received
r Need Fee - send electronic notification
r $240.00
f $570.00

s -7-
h, State of North Carolina
Department of Environ Det and Natural Resources of Water Resources
Shoreli
e Stabilization
Water Resources 15A NCAC 02H .0500 —Water Quality Certification, FORM: SSGp 02-2017
ENVIRONMENTAL QUALITY
Shoreline Stabilization Application Form
lication fee should be sent to:
Three copies of the application jincluding attachments) and they deliveryservice (UPS, FedEx, etc-)
if sending
if sending via US Postal Service Karen Higgins
Karen Higgins 401 & Suffer Permitting Branch
DWR-401 & Buffer Permitting Branch DWR— Street
512 N. Salisbury
1617 Mail Service Center Raleigh, NC 27604
Raleigh, NC 27699-1617
A.
Applicant Information f
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1. Owner Information
Name:
Mailing Address:
Telephone Number
E-mail Address:
RECEIVEDINCDE(2100
k JUN 14 2021
H VVater Q al tsection
p,,rrritting
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:
_,.-.,ra,.��.nw��r,w/reedocslf'ermits SAMPLE AGENT AUTI
ATION FORM. df)
Name: p`
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
B. Project Information [15A NCAC 02H .0502(aj�bJ1
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
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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: Nea rest Town:
Lake/ river/ ocean adjacent to property:n�
Property size (acres): 14, M acres
Subdivision name or site address (include phase/lot number): N t arg%,D F col Int1J
P f
Directions to site - please include road names and numbers, landmarks, etc.:
- - - - / ' ! . - -L„
Con e-FF' o Covt , -
F fo(/OLc� V�r
,4 rm, k n r i o S azK Or
-tv p uvis G
Latitude (in decimal degrees) 3&,14 55'f ial Longitude (decimal degrees) prate
= 17969 0303 v Q canf rot
5. Describe the existing land use or condition of the site at the time of this application (residential, undeveloped, etc.):_hjxdV d lwovcoh (Ilk-
k
Leq-
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): { (` pp pp
s i1� ran � k•v 4 a�C VAty %srst may- c awl �Cxt 41m 105 '�t� ,t,►
k\90k CvaSib+� a e1's
7. Will work be conducted from land? ® From water? ❑ Sri 4�tig
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent im acts (including II exc�vation, backfill, rip rap, retaining walls, etc.) in square feet:
� �ti�c�
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts Onclu ing back fill, excavation, rip rap, retaining walls, etc.) in square feet:
fad G(,�
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 Ian ward to be impacted (number of tregs, for instance):
1�1 c 2Q o S cv �u` W he �r (4 Yu iD 1 A 1 L�\ 1P �C� Le
FORM: SSGP 02-2017 Page 2 of 5
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11. Signature
Owner/Agent's Signature 115A NCAC H .0502(f l Date
Agents 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:
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.
P_ I ncation of anv excavation or dre&lna below the Full Pond/ Normal Water Level elevation
Full Pond/ Normal Water Lev
C= C= C= C= C=
Shoreline
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FORM: SSGP 02-2017
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Contact Name*
Contact Email Address*
Project Owner*
Project Name*
Project County*
Owner Address:*
Is this a transportation project?*
William K. Royal
[e-mail]
William K. Royal
Peninsula Place Rip Rap
Person
Street Address
315 Pebble Beach Drive
Address Line 2
aty
Mebane
Fbstal / Zip axle
27302
(- Yes c: No
Type(s) of approval sought from the DWR:
F 401 Water Quality Certification - F 401 Water Quality Certification -
Regular Express
F Individual Permit F Modification
W Shoreline Stabilization
Does this project have an existing project ID#?*
(- Yes c: No
State / Rovince / Region
North Carolina
Country
United States
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 and include location information.*
Would like to place rip rap on a new impact area located on
Peninsula Drive, Quail Hollow subdivision, Section 4, Phase 1, Lot 27.
Please give a couple of dates you are available for a meeting.
5/7/2021
5/14/2021
Please attach the documentation you would like to have the meeting about.
Royal prefile.pdf 759.23KB
Royal aerial for prefile meeting.pdf 872.05KB
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.
1 understand by signing this form that I cannot submit my application until 30 calendar days after this pre -filing
meeting request.
1 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 *
Submittal Date 4/29/2021

s -7-
h, State of North Carolina
Department of Environ Det and Natural Resources of Water Resources
Shoreli
e Stabilization
Water Resources 15A NCAC 02H .0500 —Water Quality Certification, FORM: SSGp 02-2017
ENVIRONMENTAL QUALITY
Shoreline Stabilization Application Form
lication fee should be sent to:
Three copies of the application jincluding attachments) and they deliveryservice (UPS, FedEx, etc-)
if sending
if sending via US Postal Service Karen Higgins
Karen Higgins 401 & Suffer Permitting Branch
DWR-401 & Buffer Permitting Branch DWR— Street
512 N. Salisbury
1617 Mail Service Center Raleigh, NC 27604
Raleigh, NC 27699-1617
A.
Applicant Information f
15A NCAC 02H .0502 a
(� i i I i a Yi �_ d- 5 a i e CO' Pogoe.0
912 n� r rrc rr
� I J eni•✓
M n Inl1 [1D NCB
33(c'266-0 /3FaxNumber: N
roLlGAD C Om
1. Owner Information
Name:
Mailing Address:
Telephone Number
E-mail Address:
RECEIVEDINCDE(2100
k JUN 14 2021
H VVater Q al tsection
p,,rrritting
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:
_,.-.,ra,.��.nw��r,w/reedocslf'ermits SAMPLE AGENT AUTI
ATION FORM. df)
Name: p`
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
B. Project Information [15A NCAC 02H .0502(aj�bJ1
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
Scanned with CamScanner

5--JA
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: Nea rest Town:
Lake/ river/ ocean adjacent to property:n�
Property size (acres): 14, M acres
Subdivision name or site address (include phase/lot number): N t arg%,D F col Int1J
P f
Directions to site - please include road names and numbers, landmarks, etc.:
- - - - / ' ! . - -L„
Con e-FF' o Covt , -
F fo(/OLc� V�r
,4 rm, k n r i o S azK Or
-tv p uvis G
Latitude (in decimal degrees) 3&,14 55'f ial Longitude (decimal degrees) prate
= 17969 0303 v Q canf rot
5. Describe the existing land use or condition of the site at the time of this application (residential, undeveloped, etc.):_hjxdV d lwovcoh (Ilk-
k
Leq-
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): { (` pp pp
s i1� ran � k•v 4 a�C VAty %srst may- c awl �Cxt 41m 105 '�t� ,t,►
k\90k CvaSib+� a e1's
7. Will work be conducted from land? ® From water? ❑ Sri 4�tig
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent im acts (including II exc�vation, backfill, rip rap, retaining walls, etc.) in square feet:
� �ti�c�
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts Onclu ing back fill, excavation, rip rap, retaining walls, etc.) in square feet:
fad G(,�
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 Ian ward to be impacted (number of tregs, for instance):
1�1 c 2Q o S cv �u` W he �r (4 Yu iD 1 A 1 L�\ 1P �C� Le
FORM: SSGP 02-2017 Page 2 of 5
Scanned with CamScanner

11. Signature
Owner/Agent's Signature 115A NCAC H .0502(f l Date
Agents 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:
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.
P_ I ncation of anv excavation or dre&lna below the Full Pond/ Normal Water Level elevation
Full Pond/ Normal Water Lev
C= C= C= C= C=
Shoreline
S�y4
6>
L
N
Plan View
FORM: SSGP 02-2017
Lake
(At Full Pond/!Normal Water Level)
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s -7-
h, State of North Carolina
Department of Environ Det and Natural Resources of Water Resources
Shoreli
e Stabilization
Water Resources 15A NCAC 02H .0500 —Water Quality Certification, FORM: SSGp 02-2017
ENVIRONMENTAL QUALITY
Shoreline Stabilization Application Form
lication fee should be sent to:
Three copies of the application jincluding attachments) and they deliveryservice (UPS, FedEx, etc-)
if sending
if sending via US Postal Service Karen Higgins
Karen Higgins 401 & Suffer Permitting Branch
DWR-401 & Buffer Permitting Branch DWR— Street
512 N. Salisbury
1617 Mail Service Center Raleigh, NC 27604
Raleigh, NC 27699-1617
A.
Applicant Information f
15A NCAC 02H .0502 a
(� i i I i a Yi �_ d- 5 a i e CO' Pogoe.0
912 n� r rrc rr
� I J eni•✓
M n Inl1 [1D NCB
33(c'266-0 /3FaxNumber: N
roLlGAD C Om
1. Owner Information
Name:
Mailing Address:
Telephone Number
E-mail Address:
RECEIVEDINCDE(2100
k JUN 14 2021
H VVater Q al tsection
p,,rrritting
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:
_,.-.,ra,.��.nw��r,w/reedocslf'ermits SAMPLE AGENT AUTI
ATION FORM. df)
Name: p`
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
B. Project Information [15A NCAC 02H .0502(aj�bJ1
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
Scanned with CamScanner

5--JA
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: Nea rest Town:
Lake/ river/ ocean adjacent to property:n�
Property size (acres): 14, M acres
Subdivision name or site address (include phase/lot number): N t arg%,D F col Int1J
P f
Directions to site - please include road names and numbers, landmarks, etc.:
- - - - / ' ! . - -L„
Con e-FF' o Covt , -
F fo(/OLc� V�r
,4 rm, k n r i o S azK Or
-tv p uvis G
Latitude (in decimal degrees) 3&,14 55'f ial Longitude (decimal degrees) prate
= 17969 0303 v Q canf rot
5. Describe the existing land use or condition of the site at the time of this application (residential, undeveloped, etc.):_hjxdV d lwovcoh (Ilk-
k
Leq-
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): { (` pp pp
s i1� ran � k•v 4 a�C VAty %srst may- c awl �Cxt 41m 105 '�t� ,t,►
k\90k CvaSib+� a e1's
7. Will work be conducted from land? ® From water? ❑ Sri 4�tig
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent im acts (including II exc�vation, backfill, rip rap, retaining walls, etc.) in square feet:
� �ti�c�
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts Onclu ing back fill, excavation, rip rap, retaining walls, etc.) in square feet:
fad G(,�
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 Ian ward to be impacted (number of tregs, for instance):
1�1 c 2Q o S cv �u` W he �r (4 Yu iD 1 A 1 L�\ 1P �C� Le
FORM: SSGP 02-2017 Page 2 of 5
Scanned with CamScanner

11. Signature
Owner/Agent's Signature 115A NCAC H .0502(f l Date
Agents 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:
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.
P_ I ncation of anv excavation or dre&lna below the Full Pond/ Normal Water Level elevation
Full Pond/ Normal Water Lev
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