20201916 Ver 1_Shoreline Stabilization_20210111

Submission Form
Pre -Filing Meeting Information
Before submitting this form please ensure you have submitted the Pre -Filing Meeting Request Form as we will not be able
to accept your application without this important first step. The Pre -Filing Meeting Request Form is used in accordance
with 40 C.F.R. Section 121.4(a) "At least 30 days prior to submitting a certification request, the project proponent shall
request a pre -filing meeting with the certifying agency" and in accordance with 40 C.F.R. Section 121.5(b)(7), and (c)(5)
all certification requests shall include documentation that a pre -filing meeting request was submitted to the certifying
authority at least 30 days prior to submitting the certification request. Click here to read more information on when this
form is needed prior to application submission or here to viewthe form.
Attach documentation of Pre -Filing Meeting Request here:
DWR Pre -Filing Meeting Request Form
55.95KB
(21).pdf
Pre -fling Meeting or Request Date 12/9/2020
ID# 20201916 Version 1
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:*
[e-mail]
Rease provide an er ail address for payment and requests for more infornation here.
Wesley Nathan & Audrey Gail Fox
[e-mail]
[phone]
(xxx)xxx-xxxx
Street Address
4000 Wilson Lane
Address Line 2
City
Charlotte
Rbstal / Zip Code
28206-1344
State / Frovince / Region
NC
Country
Us

Is there an agent working on the
project? *
Agent/Consultant Information
.................................................................................................................
Name:
Company Affiliation:*
Email:
Phone Number:*
Mailing Address:*
F Yes
r No
Beth Mosteller
Dale & Beth's Lake Use Permit Service
[e-mail]
[phone]
(xxx)xxx-xxxx
Address
988 Clear Creek Circle
Address Line 2
Cty
Lincolnton
Fbstal / Zip Code
28092
Asigned and dated copyof the Agent Authorization letter:*
Agent Fox. pdf 378.63KB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:* Wesley Fox
State / Province / Region
North Carolina
Country
United States
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: vicinity.docx
Latitude:* 35.466130
OANLVAI
Longitude:*-80.981030
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*
Abbreviated PCN shoreline New page 3.docx 139.46KB
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.)*

pictures.docx 55.08MB
plat.docx 877.29KB
4. Location of the property (where work is to be conducted)
Nearest Town:* Denver
County:* Lincoln
Lake/ river/ ocean adjacent to Norman
property:
Subdivisions name or site address:* F L&ARBlackLot 15
Include phasellot nunber
Directions to site:*
head southeast on W 1st St toward S Church St, Turn right onto S
Church St, Take ramp right and follow signs for I-277 South / US-74
West, At exit 1C, take ramp right for I-77 North / US-21 North toward
Statesville, At exit I IB, take ramp left and follow signs for NC-16 North,
Pass Circle K on the left in 5.2 mi, Turn right onto Optimist Club Rd,
Turn left onto Triangle Circle, Road name changes to Unity Church Rd,
Turn right onto Graham Rad, road name changes to Shipps Ln, Keep
right to stay on Shipps La, Turn sharp left onto Hinsdale Lane, Arrive at
Hinsdale Ln on the left, the last intersection is Shipps Lane
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
Residential, undeveloped, etc.
6. Property Size 0.381
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 stabilize 224 ft following contour of shoreline, one
foot above full pond, and 3-4 feet below full pond
8. How will the work be done?* I7 From Land
r1 From Water
9. Total amount of disturbance below the normal pool lake level/ normal water level:*
(including all clearing, backfill, excavation, rip rap, retaining walls, etc.)
224
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.)
224
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)
grass fescue
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):
0 $240.00 for impacts to lake (below normal water level) of less than 1 acre
0 $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, the project proponent, hereby certifies that all information contained herein is true, accurate, and complete to the
best of my knowledge and belief
o I, the project proponent, hereby requests that the certifying authority review and take action on this CWA 401
certification request within the applicable reasonable period of time.
o I agree that submission of this Shoreline Stabilization online 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');
0 1 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 the Shoreline Stabilization online form.
Full Name:* Beth MosteHer
Signature:

Initial Review
Is this accepted into the review
process?*
Project Number:* 20201916
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 AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 15 PLAN NO. PARCEL ID: 4613002993
STREET ADDRESS: Shipps Lane, Denver NC 28037 (vacant lot)
Beside 8016 Shipps Lane, Denver, NC 28037
Please print:
Property Owner: Wesley Nathan & Audrey Gail Fox
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):
4000 Wilson Lane Charlotte NC 28206
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Sig
Date: 112 - '07- go 2D

$030 /m,*
4016
SID

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
La ke
(At Full Pond/Normal Water Level)
0000000000000000000000000000000000000000
0000000000000000000000000000000000000000
Full Pond/ 0000000000000000000000000000000000000000
Normal Water Le0000000000000000000000000000000000000000
Shoreline o 0 0 0 0 0 0 0 0
224 to follow contour of shoreline,
one foot above full pond,
and 3-4 feet below full pond
Wesley Nathan & Audrey Gail Fox
4000 Wilson Lane
Charlotte, INC 28206
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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DWR Pre-Fil ing Meeting Req u est Form
ID#*Ve rsion *
Re gional Office *
Re v ie we r List *
Contact Name *
Contact Email Addre ss *
Proje ct Name *
Proje ct Owne r *
Proje ct County *
Owne r Addre ss:
Is this a transportation proje ct?*
Type (s) of approv al sought from the DWR:
Doe s this proje ct hav e an e xisting proje ct ID#?*
Do you know the name of the staff me mbe r you would like to re que st a me e ting with?
Ple ase giv e a brie f proje ct de scription be low.*
Please give a couple of dates you are available for a meeting.
20201916 1
Mooresville Regional Office - [phone]
Alan Johnson
Pre-Filing Me eting Reque st submitte d 12/9/2020
Beth Mosteller
[e-mail]
Fox
Wesley Nathan & Audrey Gail Fox
Lincoln
City
Charlotte
State / Province / Region
North Carolina
Postal / Zip Code
28206
Country
United States
Street Address
4000 Wilson Lane
Address Line 2
Yes No
401 Water Quality Certification -
Regular
401 Water Quality Certification -
Express
Individual Permit Modification
Shoreline Stabilization
Yes No
stabilization using Class B rip rap for 224 feet to follow contour of
shoreline, one foot above full pond, and 3-4 feet below full pond,
vacant lot 15 at Shipps Lane, Denver NC
Ple ase attach the docume ntation you would like to hav e the me e ting about.
Signature
Submittal Date
pdf only
By digitally signing below, I certify that I have read and understood that per the Federal Clean Water Act Section
401 Certification Rule the following statements:

· This form completes the requirement of the Pre-Filing Meeting Request in the Clean Water Act Section 401 Certification
Rule.
· I understand by signing this form that I cannot submit my application until 30 calendar days after this pre-filing
meeting request.
· I also understand that DWR is not required to respond or grant the meeting request.

Your project’s thirty-day clock started upon receipt of this application.  You will receive notification regarding meeting location
and time if a meeting is necessary.  You will receive notification when the thirty-day clock has expired, and you can submit an
application.
12/9/2020