20210179 Ver 1_Shoreline Stabilization_20210226

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:
Hicken prefiling.pdf 253.79KB
Pre -fling Meeting or Request Date 1/27/2021
ID# Version
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 * [e-mail]
Rease provide an email address for payment and requests for pure information here.
Owner Information:
Name: *
Gary Hicken
Email: *
[e-mail]
Phone Number:*
[phone]
(xxx)xxx-xxxx
Mailing Address:*
Street Address
1631 Mark Drive
Address Line 2
City State / Frovince / Region
Bridgewater Township NJ
Fbstal / Zip Code Country
08807-1229 US

Is there an agent working on the F Yes
project?* r No
Agent/Consultant Information
Name:*
Ryan Walker
Company Affiliation: *
Pineridge Construction
Email:*
[e-mail]
Phone Number:*
[phone]
(XXX)XXX-XXXX
Address:*
Street Address
2196 Sledge Road
Address Line 2
City
Louisburg
Fbstal / Zip Code
27549-9548
Asigned and dated copy of the Agent Authorization letter:*
Agent authorization. pdf 135.08KB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:* Hiicken
State / Province / Region
NC
Country
US
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
Property Address Lookup:* Street Address
751 Sagamore Drive
Address Line 2
city
Louisburg
Fbstal / Zip Code
27549
Latitude:* 35.953875
State / Province / Region
NC
Country
US
Longitude:*-78.192766
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*
751 sagl.pdf 614.56KB
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.)*
751 sag2.pdf 3.79MB
4. Location of the property (where work is to be conducted)
Nearest Town:* Bunn
County:* Franklin
Lake/ river/ ocean adjacent to Tar River/Lake Royale
property:
Subdivisions name or site address:* Lake Royale
Include phasellot nunber
Directions to site:*
From gate -Right on Shawnee Left on Ohio Right on Sagamore to 751
Sagamore
Rease include road naves and nunbers, landrrerks etc.
5. Describe the existing land use or condition of the site at the time of this application:*
Residential undeveloped lot
Fbsidential, undeveloped, etc.
6. Property Size 1.04
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
Single boat house digging 16' into shore, 16' wide 10' into water.
Construct 10 x 16 deck, retaining/sea wall around boat house & dock &
to right of boathouse approx. 74' rip wrap remainder of shore line 105'.
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, backfill, excavation, rip rap, retaining walls, etc.)
645
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.)
731
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)
12 trees, 4 dead alot of wild brush at shore and into Lake. Remove 12
tees, zonel for boathouse approx. 150 sq.ft. and 1Ox50 construction
path, 500 sq.ft.
Sketch: sketch.pdf 269.08KB
1-icken plan.pdf 426.6KB

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:* Ryan Walker
Signature:
/ y44, w4a

Initial Review
Is this accepted into the review
process?*
Project Number:* 20210179
Select Reviewer:*
Select Reviewing Office
Has payment been received?*
What amount is owed?*
rYes allo
Version:* 1
Stephanie Goss:eads\szgoss
Raleigh Regional Office - [phone]
r No Payment Needed
r Fee Received
r Need Fee - send electronic notification
r $240.00
f $570.00

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. �1 ?� PLAN NO. PARCEL ID:
STREET ADDRESS: 5 S C
-,.-.111L- 275 y 9
Please print:
Property Owner:1 i y
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
nn1 , of
(Contractor Agent) (Name of consulting firm)
to art 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):
I L 2 a
Telephone:
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
uthoriz rg a Authorized Signature
Date: iz . / 9 Date:

12. Please approximately sketch the following information an 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
La ke
(At Full Pond/ {formal Water Level)
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Plan View
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Plan view
1
FORM: SSG 02 2017
Page 3 of 4

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FORM: SSGP 02-2017 Page 4 cf 4

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Contact Name *
Ryan Walker
Contact Email Address #
[e-mail]
Project Owner
Gary Ficken
Project Name
230 Choctaw Drive
Project County
Franklin
Own e r Add re s s: *
Street Address
1631 Mark Drive
Address Ure 2
Oh
Bridgevater
Piaui Zip merle
08807
Is this a transportation project?
r Yes r- No
Type(s) of approval sought from the DWR:
r 401 Water QualityCertification - r 401 Water QualityCertification -
Regular Express
r k4vidual Permit r Modification
W Shoreline Stabilization
D*es this project have an existing project ID#7
f- Yes G No
SIM 1 Roam 1 fbglion
tW
�Y
United States
Do you know the name of the staff member you would like to request a meeting with?
Please give a brief project description below.
Baal fvouse and sea wall
Please give a couple of dates you are available for a meeting.
1127/2021
1/2812021
Please attach the documentation you would like to have the meeting about.
Ftcken appliCaGon.pdf 4.82MB
Ficken approval Army Carp.pdf Z 08MB
odl only
By digitally signing below, l 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 reguirement 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 projects 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_
Signature *
4w,or I?IA-t
Submittal Date V27)2021