20200659 Ver 1_Shoreline Stabilization_20200519

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/19/2020 12:17:48 PM (Submittal)
Approve by Montalvo, Sheri A 5/19/2020 9:10:49 PM (Non -DOT - Approver)
• The task was assigned to Montalvo, Sheri A 5/19/2020 12:17 PM

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: *
Email:*
Phone Number:*
Mailing Address:*
Is there an agent working on the
project?*
Agent/Consultant Information
Name:*
Company Affiliation:*
Email:
Phone Number:*
Renee Osborne
[e-mail]
[phone]
(xxx)xxx-xxxx
Street Address
389 Agnew Rd
Address Line 2
City
Mooresville
Fbstal / Zip Code
28117
r Yes
r No
Dean Fisher
State / Rovince / Fbgion
NC
Country
USA
Lake Norman Custom Dock & Pile Driving, Inc
[e-mail]
[phone]
(xxx)xxx-xxxx

Mailing Address:* Street Address
PO Box 1439
Address Line 2
city
State / Ftovince / Region
Denver
NC
Fbstal / Zip Code
Country
28037
United States
Asigned and dated copy of the Agent Authorization letter:*
Signed Osborne
36.56KB
AGENT —AUTHORIZATION FORM.pdf
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:* Osborne Shoreline
If your project has a formal name please use this. If your project does not hake 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
Upload Map: 389 Agnew Rd - Google Maps.pdf 514.78KB
Latitude:* 35.562783 Longitude:*-80.937240
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*
site plan.pdf 356.45KB
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.)*
image1.jpeg 149.18KB
image2.jpeg 146.61 KB
4. Location of the property (where work is to be conducted)
Nearest Town:* Mooresville
County:* Iredell
Lake/ river/ ocean adjacent to Norman
property:

Subdivisions name or site address:* 389 Agnew Rd, Mooresville NC 28117 Lot 67
Include phase/lot number
Directions to site:*
Take NC 150 E towards Mooresville. Turn right onto Morrison
Plantation Pkwy. Us the
right 2 lanes to turn right onto NC-1100/Brawley School Rd. Turn
right onto McKendree Rd.
Turn left onto Kemp Rd. Turn left onto Agnew Rd. Property is on
the right.
Rease include road narres and numbers, landmarks etc.
5. Describe the existing land use or condition of the site at the time of this application:*
Residential
Residential, undeveloped, etc.
6. Property Size 0.84
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
Grading, clearing and backfill along shoreline. Construction of
4x100ft wooded T&G seawall with 6x6 post and 4x6 whaler along
shoreline. Installation and grading of approx 6x70ft along shoreline
for RipRap with fabric.
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, back fill, excavation, rip rap, retaining walls, etc.)
830 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 walls, etc.)
2490 sq ft
square feet
11. 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)
Etasting small trees and grasses
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):
$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:
• I have given true, accurate, and complete information on this form;
• 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")
• 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');

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
I intend to electronically sign and submit this form.
Full Name:* Dean Fisher
Signature:
e,�Wr 6AOW

Initial Review
Is this accepted into the review
process?*
Project Number:* 20200659
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

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 67 _ PLAN NO. PARCEL ID: 4626-45-53348 ---
STREET ADDRESS: 383Agnew Rd., Mooresville NC 28117 _
Please print:
Property Owner: Re_[Leq Osborne _
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Dean Fisher _ of Lake Norman Custom Dock & Pile Driving, Inc
(Contractor 1 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.
Authorized Signature Authorized Signature
Dater I ,20 _______ Date:

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