20200434 Ver 1_Shoreline Stabilization_20200330

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 should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: Thomas E & Charlene M Walsh
Mailing Address: 21336 Blakey Shores Drive
Cornelius NC 28031
Telephone Number: 704-965-7634 Fax Number:
E-mail Address: [e-mail]
2. Agent/ Contact Person Information
RECEIVED
MAR 3 0 2020
NCDEQ/DWR/NPDES
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: Beth Mosteller
Company Affiliation: Dale & Beth Lake Use Permit Service
Mailing Address: 988 Clear Creek Circle
Lincolnton, NC 28092
Telephone Number: 704-996-3245 Fax Number:
E-mail Address: [e-mail]
Person to receive the Certification Approval: Beth Mosteller
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: Mecklenburg Nearest Town: Cornelius
Subdivision name or site address (include phase/lot number): 5
Directions to site - please include road names and numbers, landmarks, etc.:
see attached
Latitude (in decimal degrees) 35.494080 Longitude (decimal degrees)-80.878240
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): residential
6. Property size (acres): 0.525
7. Lake/ river/ ocean adjacent to property: Lake Norman
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Due to wave action.
9. Will work be conducted from land? ® 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: 39.86 along
shoreline
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: 39.86 along shoreline
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): grass -fescue
Beth Mosteller
Owner/Agent's Vgnature* Printed Name Date
[15A NCAC 02H .0502(f)]
'Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

La ke
(At Full Pond/Normal Water Level)
0000000000000000000000000000000000000000
0000000000000000000000000000000000000000
Full Pond/ 0000000000000000000000000000000000000000
Normal Water Level 0000000000000000000000000000000000000000
o ® 000000000000000000M00066000000'-
Shoreline
39.86' to follow contour of shoreline,
one foot above full pond,
and 3-4 feet below full pond
Thomas E & Charlene M Walsh
21336 Blakely Shores Drive
Cornelius, NC 28031
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10ftx 100ft)*:
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

CATAWBA RIPARIAN BUFFER NOTIFICATION FORM
Project Name/address: 21336 Blakely Shore Drive Cornelius, NC 28031�ounty: Mecklenburg
Owner: Thomas E & Charlene M
Print Signature
Contractor/agent: Beth Mosteller .-Lk
Print Signature
The approval is for the purpose and design described in your application. Impacts not indicated in the
application is a violation of the Buffer Rule. Site specific work should be provided in the application. [15A NCAC
02H .0506 and 15A NCAC 02B .0243(8)]
Trees are not allowed to be removed from Zone 1 of the Buffer (within 30 ft of the full pond elevation), unless
approved. Exception, those trees that are severely undermined along the immediate shoreline can be removed.
Minimal shaping and sloping along the immediate shoreline is allowed. [15A NCAC 02B .0243(6)]
Benching, grading in the buffer is not allowed. Excessive disturbance of ground cover. [15A NCAC 02B .0243 (6)]
Beaches, impervious patios, impervious walkways, etc. are not allowed in the buffer unless specifically approved
by the Division. There are limitation on size for decks. [15A NCAC 02B .0243(4) and (6)]
Work to be conducted from land must indicate an access and indicate any trees that are to be removed. The
work corridor should be described. The approved access corridor shall be restored. Staging, spoil, construction
material must be outside the buffer. [15A NCAC 02H .0502 and 15A NCAC 02B .0243 (4), (6), (8)]
Stormwater cannot be piped or channeled for direct discharge to the lake. All constructed stormwater
discharges must be at the natural elevation and discharged prior to entering the buffer directed as diffuse or
sheet flow at non -erosive velocities to the lake. [15A NCAC 02B .0243(5), (6)]
Acknowledgement of Notification
I, Thomas E & Charlene M Walsh , hereby state that I have been informed of the Catawba Riparian Buffer
Rule. Any work conducted in the buffer, not specifically stated in the application and approved by the Division
of Water Resources (DWR), is a violation and subject to enforcement. Due diligence will be taken such that the
construction will be built within substantial compliance and intent of the 401 Water Quality Certification and
Buffer Rules, the approved plan(s) and speci5gation(s), and other supporting materials.
Signature (owner) �h� Date: ; ',fib - dad

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 5 PLAN NO. PARCEL ID: 91089512
STREET ADDRESS: 21336 Blakey Shores Drive Cornelius, NC 28031
Please print:
Property Owner: Thomas E Walsh
Property Owner: Charlene M Walsh
The undersigned, registered property owners of the above noted property, do hereby authorize
Beth Mosteller , of Dale & Beth's Lake Use Permit Service
(Contractor / Agent) (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):
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
:;? 7 �-- - - 11, 5:;? /.
Authorized Signature
Authorized Signature
Date: Date:

Thomas E & Charlene M Walsh, 21336 Blakely Shores Drive, Cornelius, NC 28031;Waterford Point;
Phone [phone]; Email [e-mail]; Lot 5; PIN 91089512; 0.525 Acres; Latitude

Thomas E & Charlene M Walsh, 21336 Blakely Shores Drive, Cornelius, NC 28031;Waterford Point;
Phone [phone]; Email [e-mail]; Lot 5; PIN 91089512; 0.525 Acres; Latitude
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Thomas E & Charlene M Walsh, 21336 Blakely Shores Drive, Cornelius, NC 28031;Waterford Point;
Phone [phone]; Email [e-mail]; Lot 5; PIN 91089512; 0.525 Acres; Latitude
35.494080, Longitude-80.878240, Shoreline 39.86
Latitude and Longitude Finder
Latitude and Longitude are the units that represent the coordinates at
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Place Name
21336 Blakely Shore Drive, Cornelius NC
Add the country code for better results. Ex: London, UK
Latitude Longitude
35.494080-80.878240
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Thomas E & Charlene M Walsh, 21336 Blakely Shores Drive, Cornelius, NC 28 3 tWat rf rd Point;
Phone 7 4 96 - 6 % Email ao maswm5hnc9RmmEco m;L t \ m N 91 8 51% e525 Acres; Latitude
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Thomas E & Charlene M Walsh, 21336 Blakely Shores Drive, Cornelius, NC 28031;Waterford Point;
Phone [phone]; Email [e-mail]; Lot 5; PIN 91089512; 0.525 Acres; Latitude
35.494080, Longitude-80.878240, Shoreline 39.86
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Thomas E & Charlene M Walsh, 21336 Blakely Shores Drive, Cornelius, NC 28031;Waterford Point;
Phone [phone]; Email [e-mail]; Lot 5; PIN 91089512; 0.525 Acres; Latitude
35.494080, Longitude L-80.878240, Shoreline 639 86 y M
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