20201033 Ver 1_Shoreline Stabilization_20200812

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/10/2020 9:18:07 AM (Submittal)
Approve by Montalvo, Sheri A 8/12/2020 9:44:13 AM (Non -DOT - Approver)
• The task was assigned to Montalvo, Sheri A 8/10/2020 9:18 AM

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.
Primary Contact Email *
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:*
[e-mail]
Rease provide an enail address for payrrent and requests for rrore inforrration here.
Vincent E & Lisa M Bronikowski
[e-mail]
[phone]
(xxx)xxx-xxxx
Street Address
Post Office Box 4925
Address Line 2
City
Mooresville
Rostal / Zip Code
28117
a Yes
d No
Beth Mosteller
Dale & Beth Lake Use Permit Service
[e-mail]
[phone]
(xxx)xxx-xxxx
/ Rovince / Region
North Carolina
Country
United States

Mailing Address:*
Street Address
988 Clear Creek Circle
Address Line 2
city
Lincolnton
Fbstal / Zip Cbde
28092
Asigned and dated copy of the Agent Authorization letter:*
Agent Form.pdf 537.73KB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:* VincentBronikowski
State / Province / Region
North Carolina
Country
United States
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 Look up address
Property Address Lookup:* Street Address
142 Fern Haven Lane
Address Line 2
City
Mooresville
Fbstal / Zip Code
28117-9489
Latitude:* 35.623792
State / Province / Fbgion
NC
Country
US
Longitude:*-80.920795
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*
vicinty.docx 1.87MB
plat.docx 952.73KB
Please use the diagram at the link below:
https://edocs.deq.nc.gov/WaterResources/0/edoc/616616/Shoreline%2OLayout.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.)*
pictures. docx 2.65MB
Catawba Form.pdf 874.87KB
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:* 142 Fern Haven Lane Mooresville NC 28117
Include phase/lot number
Directions to site:*
get on 1-288 S, follow I-77 N to NC-150 W/W Plaza Drive in
Mooresville, Take exit 36 from 1-77N, Take Perth Rd and Fern Hill Rd to
Fern Hane Ln
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
Pesidential, undeveloped, etc.
6. Pro pertySize 0.64
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
due to wave action
8. How will the work be done?* Gl From Land
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 w alls, etc.)
177
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.)
177
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)
grass -fescue
Sketch: Abbreviated PCN shoreline New page 3.docx 140.41KB
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
$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
o I intend to electronically sign and submit this form.
Full Name:* BethMosteller
Signature:

Initial Review
Is this accepted into the review
process?*
Project Number:* 20201033
Select Reviewer:*
Select Reviewing Office
Has payment been received?*
What amount is owed?*
rYes allo
Version:* 1
Alan Johnsomeads\adjohnsonl
Mooresville Regional Office - [phone]
r No Payment Needed
r Fee Received
r Need Fee - send electronic notification
r $240.00
f $570.00

AGENT AUTHORJZATION FORM
PROPERTY (LEGAL DESCRIPTION:
LOT NO. 101 PLAN NO.
PARCELI6: 4628972531
STREET ADDRESS: 142 Fern Haven Lane, Moore ville NC 28177
Please print:
Property Owner: Vincent E Bronikowski
Property Owner: Lisa M Bronikowski
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.
Authorized Signature
Date: v
Authorized Signature
Date: ��

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
La ke
(At Full Pond/Normal Water Level)
0000000000000000000000000000000000000000
1111111111111111111111111111111111111111
�� � 1111111111111111111111111111111111111111
i 1111111111111111111111111111111111111111
_ 1111111111111111111111111111111111111111
177' to follow contour of shoreline,
one foot above full pond,
and 3-4 feet below full pond
Vincent E & Lisa M Bronikowski
142 Fern Haven Lane
Mooresville, INC 28177
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft 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.
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

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CATAWBA RIPARIAN BUFFER NOTIFICATION FORM
Project Name/address: 142 Fern Haven Lane, Mooresville, NC 28177 County: Iredell
Owner: Vincent E & Lisa M Bronikowski
Print Signature
Contractor/agent: Beth Mosteller :0,w1 20 n-- -
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
1, Vincent E & Lisa M Bronikowski 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 specification(s), and other supporting materials.
Signature (owner): v �� Date: