20210528 Ver 1_Shoreline Stabilization_20210416

Shoreline Stabilization Application Form
15ANCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM SSGP 10-2013
DRAFT -NOT FOR USE AT THIS TINE
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 view the form.
Attach documentation of Pre -Filing Meeting Request here:
DWR Pre -Filing Meeting Request Form.pdf 55.83KB
Pre -fling Meeting or Request Date 3/9/2021
ID# 20210528
I. Applicant Information [15A NCAC 02H .0502(a)]
Version 1
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 email address for payrrent and requests for pore information here.
Larry Gore
[e-mail]
[phone]
(xxx)xxx-xxxx
Street Address
4041 Tanglewood Drive
Address Line 2
CitY
Floyds Knobs
Rbstal / Zip Code
47119-9221
State / Rovince / Region
IN
Country
US

Is there an agent working on the
project? *
Agent/Consultant Information
.......................................................................................................
Name:*
Company Affiliation: *
Email:*
Phone Number:*
Mailing Address:*
• Yes
✓ No
Jody House
House Construction LLC
[e-mail]
[phone]
( )m-
Street Address
1626 Randalls Ferry Rd
Address Line 2
City State / Province / Legion
Norwood NC
Fbstal / Zip Code Country
28128 United States
Asigned and dated copy of the Agent Authorization letter:*
Auth Agent Form.pdf 631.29KB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:* Gore Project
If your project has a formal name please use this. If your project does not have 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.*
✓ Upload File
✓ Look up address
Upload Map: VicinityMap.pdf 2.18MB
Latitude:*
35.272935
Longitude:* -80.098385
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*
Shoreline detailed Plan.pdf 1.35MB
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.)*
Photo of 15 shoreline.pdf 139.71KB

4. Location of the property (where work is to be conducted)
Nearest Town:* Norwood
County:* Stanly
Lake/ river/ ocean adjacent to Lake Tillery
property:
Subdivisions name or site address:* Edgewater - 2020 Edgewater Drive
hclude phase/lot number
Directions to site:*
From Albemarle - take 24/27 east, Turn Right on Indian Mound. Turn
Left onto Randalls Church road. Turn Left on to Edgewater drive. House
is on right @ 2020 Edgewater Drive..
Rease include road names and nurrbers, landmarks etc.
5. Describe the existing land use or condition of the site at the time of this application:*
a single family house is being constructed on the land. Land is being
developed.
Residential, undeveloped, etc.
6. Property Size
1.7 Acers
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
We plan install Rip Rap stone shoreline erosion control. We will use
similar/same rock as being consistent with subdivision work already
done.
8. How will the work be done?*
rJ From Land
✓ 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.)
—225sf (3'x75' of
shoreline)
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.)
5,000 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:*
(nunber of trees, for instance)
We have removed approximately 4 trees in the area between the duke
energy lease line and 50' from tfor the construction of the house. We are
likely to remove an additional 12 along the shoreline. Our landscaping
budget includes the planting of approximately 35 trees in the areas where
trees have been removed - including the shoreline.
Sketch: Sketch of Veg impacted.pdf 411.5KB
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, 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");
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 the Shoreline Stabilization online form.
Full Name:*
Signature:
Jody House
d

Initial Review
Is this accepted into the review fr Yes 0 No
process?*
Project Number:* 20210528
Select Reviewer:*
Select Reviewing Office:
Has payment been received?*
What amount is owed?*
Version:* 1
Alan Johnson:eads\adjohnsonl
Mooresville Regional Office - [phone]
r No Payment Needed
r Fee Received
C' Need Fee - send electronic notification
C' $240.00
r $570.00

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO: 15R
PLAN NO: 37926 PARCEL ID: 657501159995
STREET ADDRESS:
2020 Edgewater Drive Norwood NC 28128
Please print:
Property Owner: Larry Gore
Property Owner:
The undersigned, registered property owners of the above noted property, do herebyauthorize
Jody House , of House Constrt..ction LLC
(Contractor/Agent)
(Name of consulting firm)
to act on my behalf and take all actions necessary for the process:: ing, issuance and acceptance of
permit or certification and any and all standard and special conditions attached.
Property Owners Address (if different than property abova):
this
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate tothe
best of our knowledge.
/LK- ) Cle›I't----
Authod Signature Authorized Signature
4/9/2021
Date Date

No dock or boathouse
West property line

6' Avg Bank height
2' Rip Rap above NWL
0
0
—
in

DWR Pre -Filing Meeting Request Form
ID#*
Regional Office *
Reviewer List*
20210528
Version*
1
Mooresville Regional Office - [phone]
Alan Johnson
Pre -Filing Meeting Request submitted 3/9/2021
Contact Name * Jody House
Contact Email Address* [e-mail]
Project Name* Lot 15R Edgewater
Project Owner* House Construction LLC
Project County* Stanly
Owner Address: Street Address
RandalIs Ferry Rd
Address Line 2
City State / Rovince / Region
Norwood NC
Fbstal / Zip Code Country
28128 United States
Is this a transportation project?* C Yes ( No
Type(s) of approval sought from the DWR:
I— 401 Water Quality Certification - I— 401 Water Quality Certification -
Reg ula r Express
I— Individual Permit I— Modification
l Shoreline Stabilization
Does this project have an existing project ID#?*
C Yes ( No
Do you know the name of the staff member you would like to request a meeting with?
Please give a brief project description below and include location information.*
I would like to install Rip Rap style shoreline stabilization to the
shoreline at lot 15R in the Edgewater development on lake tillery. The
/ Formal address is Edgewater Drive Norwood NC - I am available
almost anytime.. and would like to meet at your earliest convenience
Phone # [phone]

Please give a couple of dates you are available for a meeting.
3/15/2021
3/19/2021
Please attach the documentation you would like to have the meeting about.
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.
• !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.
Signature
Submittal Date 3/9/2021