20200567 Ver 1_Shoreline Stabilization_20200428

Submission Form
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.
Owner Information:
Name:*
Jill Mongene
Email:*
[e-mail]
Phone Number:*
[phone]
(xxx)xxx-xxxx
Mailing Address:*
Street Address
4295 Keisling Ridge Road
Address Line 2
City
Monroe
Fbstal / Zip Code
38573-4413
Is there an agent working on the r Yes
project?* r No
Agent/Consultant Information
Name:* Terri Kindley/ Shannon Miller
Company Affiliation:* Lake Norman Dock and Dredge
Email: * [e-mail]
Phone Number:* [phone]
(xxx)xxx-xxxx
State / Rovince / Fbgion
TN
Country
us

Mailing Address:* Street Address
PO Box 3156
Address Line 2
city
State / Rovince / Region
Mooresville
NC
Fbstal / Zip Code
Country
28117
US
Asigned and dated copy of the Agent Authorization letter:*
2020-04-27 11.05.45.pdf 235.41 KB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
...................................................................................................................................................................................
Project Name:* Jill Mongene shoreline stabilization
If your project has a formal name please use this. If your project does not ha\,e 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 ha\e 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
Upload Map: 6AA4F31B-748A-4AF5-B8B3-
4C34B4239BB1.jpeg
Latitude:* 35.585571
374.44KB
Longitude:*-80.972458
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*
989E1 994-7737-4BEA-8E6A-
1.01MB
9D699E26A350.jpeg
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.)*
16075F21-5B94-4383-8A24-
6.08MB
0165F6998F71.jpeg
69078B8F-98E2-4EAB-8844-
6.08MB
51C819FACBEAJpeg
4. Location of the property (where work is to be conducted)
Nearest Town:* Terrell
County:* Catawba

Lake/ river/ ocean adjacent to Lake Norman
property:
Subdivisions name or site address:* 1420 Roundstone Road Sherrills Ford NC 28673
Include phase/lot nunber
Directions to site:*
1-77 Exit 36 towards Lincolnton
Right on Sherrills Ford Rd
Right on Molly's Backbone, Right on Azalea Rd, Left
On Dogleg Rd, Left on Roundstone, Right on Roundstone
Rease include road naves and numbers, landmarks etc.
5. Describe the existing land use or condition of the site at the time of this application:*
Residential
Fbsidential, undeveloped, etc.
6. Property Size 1.140 AC
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
Shoreline stabilization.... refurbish existing rip rap. All work
To be done by water using barge and long reach.
8. How will the work be done? * r From Land
17 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.)
300 sq ft
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 w alls, etc.)
0
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)
0
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 have given true, accurate, and complete information on this form;
o I agree that submission of this 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 this form.
Full Name:* Terri Kindley
Signature:

Initial Review
Is this accepted into the review
process?*
Project Number:* 20200567
Select Reviewer:*
Select Reviewing Office
Has payment been received?*
What amount is owed?*
r Yes f No
Version:* 1
Alan Johnson:eads\adjohnson1
Mooresville Regional Office - [phone]
r No Payment Needed
f Fee Received
r Need Fee - send electronic notification
* $240.00
f $570.00

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.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
Pond/
Plan View
La ke
(A\ I o d/Nor ial(Otl�fertevel�--t a 1 S�� LOF iJ
l✓�l S�/tom �'
4-
Lake
im vmi renwwrmal water tml) Existing Dock
/ Wflx7h
Sy'gaz ' I�
YK...,
FORM: SSGP 02-2017 Page 3 of 4

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DocuSign Envelope ID:555F94D4-Dp9Cr49E2-BA5F-181I04C52129 j
AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO: f] PLAN NO: PARCEL
`�j ID:
STREET ADDRESS:
wrrA� . ' i ► �.�► a
Please print;
Property
Owner: ;� 1 LL MC) f,. t* N
Property
Owner:
The undersigned, registered property owners of the above noted property, do hereby
a uthorize
of
Name of consulUn
{Contractor'l�yent] ( g 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 Owners Address (if different than property above):
-q-a-q6- K-F- 1. 5 �-IL'—Jc=' &k- 7u-c"'5 - -
Telephone: Y--�
We hereby certify the above Information submitted In thls application is .ir'Cand
accurate Wthe best of our knowledge.
5ged by:noD4FlB '
r
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