20191677 Ver 1_Shoreline Stabilization_20191209

02 0/Cl1Q_t 4-
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL QUALITY 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)] FECHVEA/©EW[3tNR
1. Owner Informati n DEC 0 9 2019
Name: - C�n(ZS`1 �� VV81@ ur
Z F'�rrrii:t , cep
Mailing Address: lim
Telephone Number: C1 n FLTCf 1L ax Number: MIA
E-mail Address: �G�Sc... (JrL�r•.1.`n[-�r�) ,1-�,t�-� 4(3• w"ti
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:
http://www.saw.usace.army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
B. 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, 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 (where work is to be conducted) (�
County:rCt, �1h Nearest Town: �tJ1,Y1
Lake/ river/ ocean adjacent to property: Lc.A t�-yu cwi49-
Property size (acres): , -
Subdivision name or site address (include phase/lot number):
rections to site= please include road 1names and nG,umbers, landmarks, etc.: �i(� � Wie Rq
Latitude (in decimal degrees) Longitude (decimal degrees)
5. Describe the existing land use or condition of th,�( site at the time of this applic tion
, (residential, undeveloped, etc.): ! :e61 a0
6. Describe proposed work (include discussion as to ow hardening o`f shoreline has been
oided or why it is necessary): � �'`��C�
7. Will work be conducted from land? From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent imp s (including all excavation backfill, rip rap, retaining walls, etc.) in square feet:
�.� wp h {.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
rmanentAmpacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
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 landward to be impacted (number of Irees, for inslance): 0644, d��P.es •�
"etaorby S1-1
11. Signatu e
Owner/Agent's Signature' [15A NCAC 02H .0502(f)] Date
`Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 02-2017 Page 2 of 4

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SURVEY FOR
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NORTH CAROUNA EXTERIORS
LOT 2787, LAKE ROYALE
1353 SAGAMORE DRIVE
PIN# 2831-61-3424
D.B. 977, PAGE 746
P.R.F. 1, SLIDE 101
CYPRESS CREEK TOWNSHIP
FRANKLIN COUNTY, NORTH CAROLINA
SEPTEMBER 30, 2019
REVSIED OCTOBER 11, 2019
40 20 0 40 80
SCALE 1 "=40'
N 87'30'00" E
NIP
EDGE aF LAKE 2 7 8 7
z c ( 16,800 sq.ft.
N L 0.386 AC.
P.
LAK
IE
ROYA b8
l`
1
r
230.00'
/—,I% ANNUAL FEMA
FLOOD LIMIT ZONE "X'
MAP / 3720-2831-OOK
\ APRIL 18, 2073
PERR FR FRANKUN COUNTY CIS
IMPERVIOUS SURFACE TABLE
HOUSE
1,897 S.F.
CECK
203 S.F.
COVERED PORCH
248 S.F.
DRIVEWAY
5C8 S.F.
SIDEWALKS
90 S.F.
MISC/UTIUTIES
9 S.F.
TOTAL IMPERVIOUS AREA
Z955 S.F.
TOTAL LOT AREA
15,800 S.F.
PERCENTAGE OF IMPERVIOUS AREA 17,58%
D/YC-�P- f
CAWTHORNE, MOSS
l do PANCIERA, P.C.
Professional Land Surveyors
C-1525
333 S. White Street
Post Office Box 1253
Wake Forest, N.C. 27588
[phone]
0
VICINITY MAP
LEGEND:
EIP -EXISTING IRON PIPE
EIB - EXISTING IRON BAR
BEIP - BENT IRON PIPE
BEIB - BENT IRON BAR
NIP - NEW IRON PIPE SET
R/W - RIGHT OF WAY
CAN - CABLE TV BOX
ES - ELECTRIC BOX
TEL - TELEPHONE PEDESTAL
PP - POWER POLE
OHL - OVERHEAD LINE
WM - WATER METER
WV - WATER VALVE
CO - SEWER CLEAN -OUT
iI
U)
I a
a
0
250.00' ' SIP ;0
f*1
230.00� 1 t ,
l7
PROPOSED '. I'1
DRIVEWAY
o
PROPOSED
HOUSE
OVER
c '�
PORCH
= Zj
r
1 +5' TEL a
S 87-30'00 W PP eP
pt,
�
Z
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�EPK
TE TO AN EPK IN
THE INTERSECTICN
OF SAGAMORE DRIVE
k W ICHITA WAY
I DECLARE THAT THIS SURVEY COMPLIES WITH THE NORTH
CAROUNA STANDARDS OF PRACTICE FOR SURVEYING,
(SECTION 1600) FOR CLASS A SURVEYS AND THAT THE
CALCULATED RATIO OF PRECISION BEFORE ADJUSTMENTS
IS 1:10,000+. FU ERMORE, PROPERTY CORNERS SHOWN
ARE PRIMA ON OL MONUMENTATION FOR THE RE—
ESTA8L1S�i ENT C PROPERTY CORNERS IN THE ABSENCE
CF GRI MONUM TS AND OTHER SUBDIVISION PROPERTY
CORN S. THIS URVEY IS NOT TO BE RECORDED WITH—
OUT E WRI AUTHORIZATION OF THE SURVEYOR.
N CARo"%
20 �FESS/py'�iL':�
Q SEAL ` y
2 L-3835 r
`,t`
�
�' 1. PA",''.

AIL
Fpnkl1 n File # ,270 �Z4 PIN# 2,931-0 -3`(ZV
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H. Property Address: (37 3�c� „�.oce '�;
NCR I.CCAROLIN . Applicant or Owner N C -
NN Name: .
Environmental Health Septic/Well Permit Diagram
Building permits cannot be issue_ d nor should construction begin without Construction Authorization issuance.
Septic improvement Permit' Septic Construction Authorization (CA) �> CA Reissue** _ As Built
Well Construction Authorizatio Additional Diagram/Specifications Attached
Diagram Date**: fo/Z-� 1/ 9 EHS:
**Any previously dated CA'diagram is revokLvd and/or in slid. Confirm this is the valid diagram for the site before
beginning any construction.
Installation/grouting inspections may be scheduled the day before, or, the day of installation until 9am by contacting the
Environmental Health office at 919 496 8100. A revisit fee may apply if installation is not ready for inspection at the time
requested. Septic Operations Permits will be issued after installation is approved, all permits conditions are met, and any
outstanding fees are paid. Well Certificate of Completion will be issued after well head approval, all permit conditions are
met, and any outstanding fees are paid.
Septic Tank /600 Pump Tank
Septic Contractor
Well Contractor
FCEH FORM 165 9/19, 10/19
Drainfield Z7 Type System cc� r
_ �x � yp y � Max Trench Depth_
Septic/Pump tank dates Pump fee?496JYES pd
Well Grout date:
3�
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12ft(OUOry
IMPROVEMENT PERMIT
Franklin County Health Department
107 Industrial Drive
Louisburg, NC 27549
Phone:
For Office Use Only
*CDP File Number 290421 -1
County ID Number. 2831.61-3424
Evaluated For. NEW
PERMIT VALID UNTIL: 10/23/2024
*NOTE TO INSPECTIONS DIVISION: Buildinq Permits cannot be issued with this Improvement Permit.
Applicant:
NORTH CAROLINA EXTERIORS
Property Owner:
Address:
1422 WALL RD
Address:
City:
WAKE FOREST
City:
State0p:
NC 27587
StateMip:
Phone #:
home: [phone]
Phone #:
Address/Road #: 1353 SAGAMORE DR
LOUISBURG. NC 27549
Stricture: SINGLE FAMILY
# of Bedrooms:
# of People:
'Water Supply:
WA
PETER ELBAUM
58 LAKE ROYALE
LOUISBURG
NC. 27549
Subdivision: LAKE ROYALE Phase: NEW Lot:
Directions
1353 SAGAMORE DR
Initial SystemSystem Specifications
'Site Classification: Provisionally Suitable Minimum Trench Depth: Inches
Design Flow. 360 Maximum Trench Depth 30 Inches
Soil Application Rate: 0.3500
'System Classification/Description: Septic Tank: 1000 Gallons
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR Pump Required O Yes (Z)No O May Be Required
i C00%
*Proposed System: Pump Tank: Gallons
25% REDUCTION
Repair System Required: UYes U No U No, but has Available Space • 16n Ncac ta►.1eu • nep*Araa Exempt
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Departmen
`Site Modifications
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The
is responsible for checking with appropriate goveminq bodies in meeting their requirements.
'Permit Conditions
The Department and Local Health DopaMnant may impose conditions on the Issuance and may revoke the permits for failure of
the system to satisfy the conditions, the rules. or this article. This permit Is subject to revocation it the site plan, plat, or intended
use changes (NCGS 13eA-335M). The person owning or controlling the system location. Installing, operation, maintenance,
monkorina. moartino. and reoatr 1.1918rb11.
Authorized State Agent: Shad Leonard Date of Issue: 10/23/2019
Total Time: (HH:tMA)
0 Hand Drawing 0 Import Drawing "Site Plan/Drawing attached"

Construction Authorization For Office Use Only
l l �n Franklin County Health Department *CDP File Number. 290421 -1
' l l I1 107 Industrial Drive Courriy ID Number. 2831-61-3424
oun�
Louisburg, NC 27549 Evaluated For. NEW Phone: PERMIT VALID UNTIL: 10/23/2024
'" � Open Pump System Sheet
Applicant: NORTH CAROLINA EXTERIORS Properly Owner. PETER ELBAUM
Address: 1422 WALL RD Address: 58 LAKE ROYALE
City: WAKE FOREST City: LOUISBURG
State/Zip: NC 27587 State0p: NC. 27549
Phone #: home: [phone] Phone #:
Property Location 3 Site Information
Address/Road #: 1353 SAGAMORE DR Subdivision: LAKE ROYALE Phase: NEW Lot:
LOUISBURG, NC 27549 Directions:
Structure: SINGLE FAMILY 1353 SAGAMORE DR
# of Bedrooms: 3
# of People: 3
'Water Supply: COMMUNITY
el System Specifications
*Site Classification: Provisionally Suitable Minimum Trench Depth: Inches
Design Flow: 360
Ma
Soil Application Rate: 0.3500 bmum Trench Depth: 30 Inches
*System ClassificationlDescription: Minimum Sol Cover. Inches
TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Ma)d mum Soil Cover. Inches
*Proposed System:
25% REDUCTION *Distribution Type: GRAVITY -PARALLEL (eq. d bmr)
Septic Tank 1,000 Gallons
Nitrification Field: Sq. ft.
No. Drain Lines: 5
Pump Required: OYes ©No O May Be Required
Olnches O.C. Total Trench Length: 270 ft. ©Feet O.C. Pump Tank: Gallons
Trench Spacing: _ 9 Olnches Grease Trap: Gallons
Trench Width: _ 3 (Z)Feet
Septic Tank Installer
Aggregate Depth: inures Grade Level Required: O 1 O 11 O 111 O IV
The issuance of this permit by the Health Department in no way guarantees the Issuance of other permits. The permit holder
`Permit Conditions: is responsible for checking with appropriate governing bodies in meeting their requirements.
1., :1
The Auffmizallon for Wastewater System Construction shaft be valid for a period equal to the period of validity of the Improvement Permit and
may be Issued at the same time the Improvement Permit issued (NCGS 130A-336(b)). If the installation has not been completed during the
period of validity of the Construction Permit, the information submitted in the appticadon for a permit or Construction Authorization shall became
invalid. and may be suspended or revoked (A 937(g)). Thor person owning or controlling the system shall be responsible for assuring
compliance with the laws, rules, and permit conditions regaurding system location, installation, operation, maintenance, monitoring, reporting
Authorized State Agent: Shad Leonard Date of Issue: 1023/2019
**Site Plan/Drawing attached"
O Hand Drawing O Import Drawing Total Time: (HH:MM)
Page 1 of 1

SURVEY FOR
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NORTH CAROUNA EXTERIORS
LOT 2787, LAKE ROYALE
1353 SAGAMORE DRIVE
PIN# 2831-61-3424
D.B. 977, PAGE 746
P.R.F. 1, SLIDE 101
CYPRESS CREEK TOWNSHIP
FRANKLIN COUNTY, NORTH CAROLINA
SEPTEMBER 30, 2019
REVSIED OCTOBER 11, 2019
40 20 0 40 80
SCALE 1 "=40'
STE
VICINITY MAP
LEGEND:
EIP — EXISTING IRON PIPE
EIB — EXISTING IRON BAR
BEIP — BENT IRON PIPE
BEIB — BENT IRON BAR
NIP — NEW IRON PIPE SET
R/W — RIGHT OF WAY
CAN — CABLE TV BOX
EB — ELECTRIC BOX
TEL — TELEPHONE PEDESTAL
PP — POWER POLE
OHL — OVERHEAD LINE
WM — WATER METER
WV — WATER VALVE
CO — SEWER CLEAN —OUT
0
x
r
D
O
D
N 87'30'00" E
230.00' 13.5' —_
NIP}\\--- --t -"j-
o PROPOSED
EDGE OF LAKE 27 Q 7 HOUSE
16,800 sq.ft. OVER
. 0.386 AC.
' 1315'
EIe
230.00' '
/_—_I% ANNUAL FEMA
1
FLOOD LIMIT ZONE "A"
MAP 0 3720-2831 - OOK
\ DATED 16, 2D13
PER FRANKUNKLIN COUNTY GIS
'
IMPERVIOUS SURFACE TABLE
HOUSE
1,897 S.F.
DECK
203 S.F.
COVERED PORCH
248 S.F.
DRIVEWAY
508 S.F.
SIDEWALKS
90 5.F.
MISC/UTIUTIES
9 S.F.
TOTAL IMPERVIOUS AREA Z955 S.F.
TOTAL LOT AREA 16.80C S.F.
PERCENTAGE OF IMPERVIOUS AREA 17.58%
250.00'
.0'
S BT30'00" W
me
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EIP m
N
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w Z7
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;E
AY
O
o -0
TEL
PP UP
CIP
o r'�
O�
1 \ EPK
TIE TO AN EPK IN
THE INTERSECTION
OF SAGAMORE DRIVE
& WICHITA WAY
I DECLARE THAT THIS SURVEY COMPLIES WITH THE NORTH
�J` N CAROLINA STANDARDS OF PRACTICE FOR SURVEYING,
1 1 (SECT ON 1600) FOR CLASS A SURVEYS AND THAT THE �-, �� y
�••/ CALCULATED RATIO OF PRECISION BEFORE ADJUSTMENTS O FEss/per L
CAWTHORNE, MOSS IS 1:10,000+. FU ERMORE, PROPERTY CORNERS SHOWN "'" u, ti9 9 L
& PANCIERA, P.C. ARE PRIMA ON OL MONUMENTATION FOR THE RE- _ =Q
ESTABLIS ENT 0 PROPERTY CORNERS IN THE ABSENCE - i SEA
OF GRI MONUMITS AND OTHER SUBDIVISION PROPERTY L-3835
Professional Land Surveyors � €
CORN S. THIS SURVEY IS NOT TO BE RECORDED WTH— q-'
C-1525 = cv N 10
OUT E WRI AUTHORIZATION OF THE SURVEYOR.
333 S. White Street �:,�� SUfi`1� ��,``
Post Office Box 1253 0
Wake Forest, N.C. 27588 �''.,r' . PP`
[phone] OFESSIONAL LAND SURVEYOR L—

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DWR State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification
Instructions for Application FORM SSGP 10-2013
(Shoreline Stabilization 401 WQC to accompany USACE GP30, GP79, or GP80)
Instructions for Shoreline Stabilization Application
When to use this form — This application form should be used to apply for a 401 Water Quality
Certification to impact:
U.S. Army Corps of
Description
Engineers (USACE) Permit
Federal Energy Regulatory Commission (FERC) regulated lake
shore or bottom
GP30
Tennessee Valley Authority (TVA) regulated lake shore or bottom
GP30
Local government regulated lake shore or bottom
GP30
USACE Reservoir owned/regulated lake shore or bottom
GP79
Private lake shore or bottom
GP80
When this form should not be used — This application form cannot be used for wetland or
stream impacts. This information does not apply to landowners within the twenty coastal
counties that are affected by Division of Coastal Management (CAMA) rules.
For more information — If you have been advised that you require a 401 Water Quality
Certification, and would like more information about:
➢ The application process: http://portal.ncdenr.org/web/wq/swp/ws/401/certsandpermits
How to download an application form:
http://Porta1.ncdenr.org/web/wq/swp/ws/401/certsandpermits/apply/forms
➢ Application fees:
http://Portal.ncdenr.org/web/wq/swp/ws/401/certsandpermits/apply/fees
If you are unable to download this information or application, please call [phone] to
request an application with instructions.
Please note — Not all impacts require written authorization from DWR. This may include the
construction of docks or boathouses if there is no dredging or filling involved (other than the
pilings). For more information, please visit the following website:
http://portal.ncdenr.org/web/wq/swp/ws/401/certsandpermits/fags#always have to apply
How to apply — When submitting an application to DWR, please use the following instructions
as a checklist in order to ensure all required items are submitted. Adherence to these
instructions will help facilitate a quicker review time and reduce the amount of requested
additional information.
INSTRUCTIONS FOR APPLICATION SSGP307980 08-13 & SUPPORTING DOCUMENTATION Page 1 of 3

Provide three (3) copies of the application and supporting information (maps, drawings, etc.),
as well as the appropriate application fee (see below), to the Division of Water Resources,
401 & Buffer Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617.
Applicant Information
Owner Information: Please provide complete and accurate contact information
❑ Agent Information: Per 15A NCAC 02H .0502 , an agent may be given signatory
authority for the owner/applicant if a signed and dated copy of an Agent Authorization
letter is included with the application. (A sample form may be found at
http://www.saw.usace.army.mil/Portals/59/docs/regu latory/regdocs/Permits/SAMPLE
AGENT AUTHORIZATION FORM.pdf)
[
Proj t Information
vicinity/ Site Map: Some type of site map so that someone unfamiliar with the area can
locate your project. A county map or USGS topographic map indicating the project
ocation is usually sufficient.
Site Plan: A site plan showing the location of the shoreline, location of the impacts to
the shoreline and/or lake bottom and the location and any vegetated areas that will be
impacted. In most cases the site plans do not have to be professionally prepared.
However, if you intend to conduct hydraulic dredging, professionally prepared drawings
will likely be required for the spoil structures. See example below.
Photograph of shoreline to be impacted/ disturbed
Description of property (including location information and lat/long coordinates) and
xisting features on and near the site
Description of project and impacts/ disturbance proposed
III. Si ture
Per 15A NCAC 02H .0502 , the application shall be considered a "valid application" only
if it bears the signature of a responsible officer of the company, municipal official,
partner or owner. This signature certifies that the applicant has title to the property, has
been authorized by the owner to apply for certification or is a public entity and has the
power of eminent domain.
IV. App cation Fee
The application must be accompanied by the appropriate application fee (checks made
out to the NC Division of Water Resources). The application fee is as follows (pursuant
to G.S. 143-215.3D):
➢ $240.00 for impacts to lake (below normal water level) of less than 1 acre
➢ $570.00 for impacts to lake (below normal water level) of greater or equal to 1 acre
INSTRUCTIONS FOR APPLICATION SSGP307980 08-13 & SUPPORTING DOCUMENTATION Page 2 of 3

EXAMPLE
La ke
(At Full Pond/ Normal Water Level)
, Dock
30ftx7ft
Excavated Area
25 ft x 150 ft
Full Pond/ Rip Rap3ftx 150ft
Normal Water Level • , Below full pond/ NWL
Shoreline
�• Rip Rap
3ftx150ft
Cleared Area Above full pond/ NWL
8ftx150ft '
Lot A
Existing
5 ft
10 ft /
Proposed
Additional clearing
5 ft
INSTRUCTIONS FOR APPLICATION SSGP307980 08-13 & SUPPORTING DOCUMENTATION Page 3 of 3