20191574 Ver 1_Shoreline Stabilization_20191113

State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Division of Water Resources FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee shout befit
to:
If sending via US Postal Service
Karen Higgins
DWR — 401 & Buffer Permitting Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
1. Applicant Information [15A NCAC 02H .0502(a)] RECBVE01©ENRr®WR
1. Owner Information NOV 13 2019
Name: JJJJ LLC �Ajsjw iReaources
Mailing Address: 10 Jackfield Road P'arnnit:kig Sect"
Bluffton, SC 29910
Telephone Number: 843-384-8822 Fax Number:
E-mail Address: [e-mail]
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.mil/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,
etc.), rip rap, excavation or dredging below Full Pond/ Normal Water Level elevations,
FORM: SSGP 10-2013 Page 1 of 3

11
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: Montgomery Nearest Town: Mt. Gilead
Subdivision name or site address (include phase/lot number):
196 Bie Oak Lane. Mt. Gilead. NC 27306
Directions to site - please include road names and numbers, landmarks, etc.: _
From Albemarle — turn onto NC/24 E/ NC 27 W / NC -73. Continue about
6 — 7 miles. Turn right onto Lilly's Bridge Road — and travel approx. 5 miles to Alex Daly Dr.
Turn right —and destination will be on the right.
Latitude (in decimal degrees) 35.227867 Longitude (decimal degrees)-80.063085
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Residential Developed
6. Property size (acres): .43 acres
7. Lake/ river/ ocean adjacent to property: Lake Tillery
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): New Pier, Boathouse and shoreline rip rap
9. Will work be conducted from land? ® From water? FJ
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:
158x6=948ft.
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: 158' x 6' = 948 ft.
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):
Normal
FORM: SSG 10-2013
Page 2 of 3

Owner/Agent's Signature` (15A NCAC 02H .0502ff)] Date to 131' 1
Agent's signature is valid only if an authorization letter from the owner is provided.
Lake
(At Full Pond/Normal Water Level)
Full Pond/
Normal %AIntcr I o.,ol
St
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as loft 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.
S. 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

QJ� ONO
LI I_i_Y�S Apt
i'd

577E PLAN SUR1£r FCW
JJJJ, LLC
The R.combNed Lot Ne. 19 of the 'LMj. BeApm Late by
PROGRESS ENERGY CAROUNAS, INC.
Deed Raferaee Book 757 Pape 351
ML Glead T._.Jp, Mantgomry County. North Carolina
Located at 196 Big Ook tune, Mt. Mead. NC
Sarwyad by Thamae a FNWe, PLS-2905. and A iota, In Warr 2018.
RENSED . UPDATED on Apr9 25th, 2019.
TOTAL AREA = 0.43 Acre t
h ae.dnetr
2O 0 20
Srds Y b fen
Y� 7r
From the office of
WRi T & FIELDS LAND SURVEYING
1340 Albemarle Road, Su Re C
Troy, N.C. 27371
Phan. No.: 910-572-2449
GENERAL NOTES
1. The Porcd ID Number for the wb*t
fr the eubjecl properly M
6583-00-29-5535.
2. See Acoea Eaemnent attached to the
U ery deed reoora.d In Deed Book 494
Pop 112
3. Bow an FEMA flood Map 371f16.583001K.
We properly M lacaled in Zone 14 an are
of Minimal Flood Rle,
4. The Baa Flood Devotion 'r 278.3 Feet
S.
The Montgomery County Cl
records"*
wbpct property as bung Zaned R-1.
6. Minimum Bu9ding Setbadn
Front ....... 30 FM
Snee ....... 10 Feet
Rear ....... 20 Feel
Lakeeloe .. 10 Feel
7. Sea th0' -4.1' rate oonosming eonfarmfly
and non- famRy of theee late inreepaet
to Montgomery
County SubdNMlon s: 2onng
Ordinance found an th. third page of Deed
Boak 757 page 352 and being an eeerpt from
a letter by Mr. PhD Hanley, former Balking
nw..tor for Montgomery County
I owtNy that thin plat rraan epl. o eawy of
another category, win as the recombination
of aMling parc.W o court-order.a wmy a
other exception W the deft itan of wbd ale r.
Sumyor
NORTH CAROLINA
MONTGOMERY COUNTY
L Thoma a FWde, ortify that th"s plat sa
prepared ham an aewd = dane by me n
October 201s ham nfarmatan round In
do.ds a referenced an thin plot and le n di
re.p.eb eared to the bat of my knam dge
and bdiat The ratio of procl.ion doulate0
by lotlwdes and departure b 1 15,000'f
that thin Plot sa prapaed inaoeardaas wltb
G.S. 47-30 as amended Iffit a my rlpinal
elpnatu and official .tamp r eed this the
25th day of Ar9 2019
weWrae RS _ — Na _
No horizontal control rRdn 2000 fat
Line Legend
Boundary Leas
Adj;—t BouiWarbs (not wmyea)
..........�be�ee�.eeo�nao.w .........
- - Rkghl_of-Way Li;*;
Lake Front Nlemtton Ur; ---
House
9ymbul taped
0 ...... _.tee mmn umat. lae
al ae not" an plat.
v4,r �
SITE o
Big Oalt tone w�E
tS
Not to sod ,
VICINITY MAP
Olmers by GS Records:
Wodesbcro Booting Gub
Duke Energy Progress Inc.
Truman C. Nonce Hers
PIN." 6584-00-41-8718
�t I h
Job No. 2018-154

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