20210686 Ver 1_Shoreline Stabilization_20210519

Shoreline Stabilization Application Form
15ANCAC 02H .0500 — Water QualityCertification, 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:
Busby DWR Pre -Filing Meeting Request
51.46KB
Form.pdf
Pre -fling Meeting or Request Date 4/2/2021
ID# 20210686
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 payment and requests for more information here.
Sarah Busby
s arahpbus by@gmail. c om
[phone]
(xxx)xxx-xxxx
Street Address
5 Oak Road
Address Line 2
City
Salisbury
Fbstal / Zip Code
28144-6909
State / Rovince / !Region
NC
Country
US

Is there an agent working on the
project? *
Agent/Consultant Information
.......................................................................................................
Name:*
Company Affiliation: *
Email:*
Phone Number:*
Mailing Address:*
C' Yes
r No
Donna P Hrko
Lancaster Custom Dock and Lift Systems, Inc.
donna. lane asterdocks@gmaiL com
[phone]
( )m-
Street Address
1156 Perth Road
Address Line 2
City State / Province / Region
Troutman North Carolina
Fbstal / Zip Code Country
28166 US
Asigned and dated copy of the Agent Authorization letter:*
Busby Signed Agent Authorization Form.pdf 144.89KB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:*
Busby Dredge and Shoreline Refresh
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.*
r Upload File
C' Look up address
Property Address Lookup:*
Latitude:*
35.580810
Street Address
321 Grasshopper Circle
Address Line 2
City State / Ftovince / F bgion
Mooresville NC
Fbstal / Zip Code Country
28117-6615 US
Longitude:* -80.929166
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*

Busby Buffer Notification and Site Plan.pdf
Busby Duke Energy Excavation Application
and Supplemental Information.pdf
Please use the diagram at the link below:
669.96KB
6.61 MB
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.)*
Busby Shoreline Photos.pdf 759.45KB
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:* Crescent Land+ Timber Corp. Section 8 Lot #443
hclude phase/lot number
Directions to site:*
From I-77 NB Exit 35, Left onto Brawley School Road, Right onto
McKendree Road, Right onto Grasshopper Circle, Keep right at the "Y"
and continue on Grasshopper Circle, Property is on the right.
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
.55 Acres
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
Dredge area for boat slip access to new dock to be constructed.
Shoreline refresh of rip rap at base of existing timber wall and on back
right of dock where wall does not extend as shown on drawing for
stabilization and erosion control.
8. How will the work be done?*
rJ From Land
17 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.)
2,934 sf
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.)
746 sf incl. const.
corridor
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)
None
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):
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:
Donna P. Hrko

Initial Review
Is this accepted into the review fr Yes 0 No
process?*
Project Number:* 20210686
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: 443
STREET ADDRESS:
321 Grasshopper Circle
PLAN NO: PARCEL ID: 4627614803
Mooresville, NC 28117
Please print:
Property Owner: Sarah Busby
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Donna P. Hrko , of Lancaster Custom Docks and Lift Systems, Inc.
(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 Owners Address (if different than property above):
5 Oak Road
Salisbury, NC 28114
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate tothe
best our knoiiedge,
Authorized Signature
Authorized Signature
Date 5/3/2021 Date

Project Rlame/eddress:
Owner: 5C+`r
Print
Contractor/agent
PA JJAN BUFF [ 3 NO'GRCAnORVORIM
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 riot 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. j15A NCAC 02B .0243
(5)]
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. 115A NCAC 02B .0243(4) and (6)]
Work to be condlucted 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 028 .0243 (4), (6), (8)]
Storrnwater cannot be piped or channeled for direct discharge to the lake. All constructed stormweter
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 0213 .0243(5), (6)]
Acknowledgement of Nottfmion
1, hereby state that I have been informed of the Catawba
Riparian Buffer Rule. Any work coed ed 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
rnaterials.
Signature (owner):
Date:
5- -Z1

Water Resources
ENVIRONMENTAL QUALITY
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 0211 .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 02-2017
Please approximately sketch the following information on 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
Full Pond/ Normal Water Level
Shoreline
Plan View
FORM: S5GP 02-2017
Pull Pend/ Normal Water Level
2 ft.x 150 ft.
addnonr l deanng
• H necessary
Plan View
Lake
(At Full Pond/ Normal Water Level)
ra.p bast.
Lake
lA[ Full Po.d/Norrca/ Weer ievel]
Existing Dock
30 kx 7 ft
/1Nof-fa5cje
ZA6926f
4044: 0D'
Dred e-Avea_
IN recto ur
CA7 obipond.
— —1)ais‘'i
t.
_+a7` rtprapr
3 f e 150 ft
Below Al pond/ NWL
.1= MAW -
4 Ni 15011
Above feel pond/ NWL
E
54`x 1 54 F
Page 1 of 3

-1
r�f` ti
1
•
97 Feet
Iredell
Printed October 14, 2020
See Below for Disclaimer
Addresses
A InfrastructLre
▪ NonResidential Use
• Residential Use
Streets
— interstate
Ramp
— US Hoy
State Hti4y'
— Main Road
Local Road
Residential
Private
Ina ti.e
Parcels Hooks
Parcels
0
Ci;y• Limits
Lake Normar
€rec ell Couryiire
NC Counties
The maps prepared for this website we generated from recorded deeds, plats, and other public records. Users of these maps are hereby notified that the information
❑rovided herein should be verified. Iredell County assumes no legal responsibilities for any of the information contained on this site. Users are advised that the use of
any of this information is at their own risk. All maps on this site were prepared using a 1000A€"' Grid based upon the North Carolina State Plane Coordinate System
from the 1983 North American Datum. The delinquent real property tax overlay is updated monthly. The information presented is not intended to be used or relied upon
as official notice of tax liens. For additional Information regarding delinquent taxes, contact the Iredell County Tax Collector's Office.

Duke Energy Lake Services
Guidance for Completing an Excavation Permit Application
Note: If you are proposing excavation in association with the permitting of a new
or expanded facility under the Marina or Conveyance Programs, you do not need
to complete this application. Instead, you should incorporate the excavation
request into the permit application for the marina/conveyance using the
appropriate application.
Step 1: Contact Duke Energy Lake Services
Complete "Part I" of the application and develop a drawing of the proposed excavation area.
Contact Duke Energy Lake Services to schedule a site visit. Lake Services will conduct a site
visit to determine if Duke Energy will accept an excavation permit application for the proposed
work. If the Lake Services representative determines the application process may proceed,
he/she will initial Part I of the application.
Step 2: Draft Application Development
Complete Parts II-III.A-G and Part V of the Excavation Permit Application.
Step 3: Agency Consultation
Send the draft application developed during Step 2 to the agencies for review and comment on
the proposed activity. Refer to the Agency / Organization List available from Duke Energy to
determine which federal, state, regional, and local agencies and organizations require
consultation or review.
Note: Duke Energy reserves the right to require consultation with additional organizations
beyond those included in the Agency / Organization List.
Each agency / organization must be provided at least 30 days prior notification. Evidence must
be provided (e.g., response letter or Certified Mail receipt) in the complete application to show
each agency / organization was given the opportunity to review the proposal.
Consultation letters must be dated within the two years preceding Duke Energy's receipt of the
application. All permits must be valid at time of application and have a term longer than the
projected schedule for completing the permitted project.
What to Expect During Agency Review and Comment:
• You will typically receive a letter from each agency / organization either documenting its
concurrence with your proposal, requiring additional information, recommending
modifications. or offering no comment. You must address each agency's / organization's
comments with a follow-up letter and in your final application as described in part IV.
• If you do not receive any documentation from an agency / organization within 30 days of its
receipt of your proposal, you must provide the agency / organization with a follow-up letter
requesting comment on your proposal within 15 days from the date of the follow-up letter. If
you still do not receive any response as a result of the second letter, type "NO RESPONSE"
Duke Energy
Excavation Program
Page 1 of ] 3 rev 1O/112019

at the top of the follow-up letter and include it in the application along with proof of the
agency's / organization's receipt of the letter (e.g., Certified Mail receipt). You may proceed
with the application process recognizing, however, that if its comments come later in the
application process, you will be required to address them.
• From the United States Army Corps of Engineers (Corps): (* * Note — The Corps may have
additional forms to submit for your proposal and an additional fee.) If the excavation can be
done under the requirements of the General Permit (GP) or a Nationwide Permit (NWP), you
will typically receive a copy of the Corps' tear sheet documenting authorization and
providing any additional instructions. If the excavation isn't covered under the GP or a
NWP, you'll be required to obtain an individual 404 Dredge and Fill permit from the Corps.
You must receive written documentation from the Corps that your application either (1)
meets the requirements of the GP or a NWP or (2) the proper 404 Dredge and Fill permit has
been received before Duke Energy can process your application.
• From the North Carolina Department of Environmental Quality (NCDEQ), Division of
Water Resources: (Note —NCDEQ may have additional forms to submit for your proposal
and an additional fee.) If the proposal meets the requirements of the Clean Water Act Sect.
401 Water Quality Certification, you will typically receive a letter from the NCDEQ Division
of Water Resources documenting Sect. 401 Certification and providing any additional
instructions. You may also receive a letter requiring additional information or
recommending modifications. You must receive written documentation from NCDEQ
noting any required Sect. 401 Certification has been received before Duke Energy can
process your application.
• From the North Carolina Wildlife Resources Commission (NCWRC): If you do not receive
any documentation from the NCWRC within 30 days of their receipt of your application, you
may proceed with the application process without submitting a follow-up request,
recognizing however if comments come in later in the application process, you will be
required to address them.
• From the South Carolina Department of Health and Environmental Control (SCDHEC):
(Note — SCDHEC may have additional forms to submit for your proposal and an additional
fee.) The SCDHEC conducts a joint application process with the USACOE in S.C. If the
proposal meets any applicable requirements of the Clean Water Act Sect. 401 Water Quality
Certification, you will typically receive a letter from SCDHEC documenting Sect. 401
Certification and providing any additional instructions. You may also receive a letter from
USACOE requiring additional information for the agencies participating in the joint
application process. You must receive written documentation from SCDHEC noting Sect.
401 Certification has been received if required before Duke Energy can process your
application.
• From the South Carolina Institute of Archaeology and Anthropology (SCIAA): The applicant
must wait 30 days after receiving the signed postal returned receipt. If a response from
SCIAA has not been received by this time you may proceed with the application process
without submitting a follow-up request, recognizing however if comments come in later in
the application review process, you will also be required to address them.
Duke Energy
Excavation Program
Page 2 of 13 rev 10/1/2019

Step 4: Final Application & Submittal to Duke Energy
Following the consultation process, finalize the application. The final application submitted to
Duke Energy should incorporate all comments and recommendations provided by agencies and
organizations during the agency consultation process as well as copies of all permits received. In
addition to the final application include the following:
• One check payable to Duke Energy for the application fee and security deposit
• If applicable, a separate check payable to the appropriate Habitat Enhancement Program fund
• Signed Excavation Program Applicant's Agreement
Note: Co -applicants must also submit the application fees and applicable HEP fees with the
application.
Duke Energy
Excavation Program
Page 3 of 13 rev 30/1/2019

Duke Energy Excavation Permit Application Form
FOR DUKE ENERGY USE ONLY
Duke File No.
Application Fee $ Security Deposit $ Check # Date Recv'd Initials
Date of Duke Energy Lake Services. applicant and/or contractor on -site inspections Date 4 Z 2 Zlttitials
412 11i
Date Final Protection/Avoidance Area Markings Field - Verified Initials
Approved to Start Work By * : Date
(Print) (Sign)
Date Completion Required Date of Any Approved Extension Initials
Date Passed Closeout Inspection* Initials
Any Stop Work Orders or SMG Violations*? (check one) ❑Yes No (If Yes, explain in PART V)
Date Deposit Refunded Initials Date Permit Database Updated Initials
* Forward copy of approved application (all pages, plus any attachments that Duke Energy changed) back to applicant
with Approval Letter and highlight any changes. File copies of Approval and Close-out Checklists and any Stop Work
Orders with a s s lication.
Part I. Applicant Information (Please Print)
Name
Email address:
Sarah Pu4,11
cxra1f-I p busbki P sv-nr-i i l, c n m
Lake Address Mailing Address (f different)
J?���ra_ ��n j- CI e. [ Ll 1' R(-1.
Telephone '70i - 2OZ - 03 73
ivinnresvl 11e, N\ C zB 117 Sclil isbur� MC. Let l4-
Contractor Company
Contractor Contact Person
Contractor Email Address:
u
flc n nc P 14r 12
donne . 1QuncALT1-p
Telephone 304. L q_ C,0(467
r-doc.1.1683rnciim
LAKE LOT INFORMATION
1lC P! [�27( 14&o3
Lake �p,r�gyl County 1 re.c]e i I Cityooresvl 11� State Tax MapNo.
Subdivision ere r - Lana + Lot / Section No.143/ e Lot Size .55 Acres
—rt nriber Corp,
Duke Energy
Excavation Program
Page 4 of 13 rev 10/1i2019

Duke Energy Excavation Permit Application Form
Are there any Co -Applicants*? (check one) ❑ Yes Jo (If Yes, include names, street
addresses or lot numbers, pier numbers, phone numbers, and email addresses in Part V —
Additional Information)
* Co -Applicants exist when the proposed work is being done under a single application, will be
performed by a single contractor as one continuous project, and is done to benefit multiple
owners / lease holders of Project -front properties within a single development. There can be no
more than 4 co -applicants in addition to the lead applicant on any application.
Do not continue the application until an on -site inspection has been conducted between a
Duke Energy Lake Representative and the applicant and/or the excavation contractor.
NOTE: Initialling this portion of the application by a Lake Representative in no way
constitutes approval or eminent approval of the excavation or any other lake use permitting
activity.
Date of on -site inspection 4 Z Z 1
Initials (Duke Energy) J R jC 11`
Duke Energy
Excavation Program
(applicant/contractor) C
Page 5 of 13 rev 10/1/2019

Duke Enemy Excavation Permit Application Form
Part 11. Description of Project
A. Basic Information
1. Type of excavation: (check one) CR.New excavation ❑ Maintenance excavation
2. Purpose of excavation: (check one) Rf Boat Access Channel
❑ Water Intake Channel ❑ Wastewater Discharge Channel
0 Other (spec):
3. Lake user category: (check one) Z.Private ❑Residential Marina
❑Commercial Marina ❑Public
❑Other (spec):
4. Max. Excavation Area Dimensions (ft): Length 54 Width 48 Depth /0
(Note: include additional area dimensions if necessary so response to #5 below equals max. area
dimensions in #4)
5. Volume of Excavated Material (TOTAL for the project): 2.5() Cubic yards
6. Type of material removed (applicant determines by. field sample if practical): �Cu�1d, slit cloy
7. Excavation Site area: .OJT 95 Acre (s) Disposal Site area: . Qom' Acre(s)
8. Total Disturbed Area (including equipment staging area): . 0955 Acre (s)
9. Does the project meet the requirements of the applicable General Permit? (check one)
ees Vo
10. Do you claim title to the disposal area? (check one) ❑Yes
1a
11. Do you claim title to the equipment staging area? (check one) I7`Yes Vo
12, Are there any water -treatment facilities within 50 feet of the proposed excavation area?
(check one) Yes Rio
(If Yes, sped):
13. How will the excavated material be entrapped and the erosion controlled? (e,g. see attached
erosion control plan and disposal area design): �14 ]r�� �\N - \'\ 1prtL� rreachex��ccis na+eri 0.1 i n I/ Dp� h e,5 Rao 10.Wckv lt] `''tOgr � 'o o 1 DG.d
onirucitivylp -iruL11)5Gtnc spor-+ -ha di sal 5 e
Duke Energy
Excavation Program
Page 6 of 13 rev 10/ 1 /2019

Duke Enerey Excavation Permit Application Form
14. Type(s) of excavation equipment to be used:
Lona,
regch exC Jc--& 511or+ reotc.11 e?tc cd-or bckrcdes, d uorYtp
15. Will waters or wetlands be crossed in transporting equipment to or from the site?
(check one) j Yes ENo
(If yes, explain)
Afl d`r do n eg0ipry) en+ iS+r& or+ed via-laciliVI ICIVI1+1,fu�J
bOct -- r0 v:Y- + CL.Yl C&S f r � sit) m dc. I 4y'eq 4 44 - w
c� Tao-pr5I +e On LQAe 1,
1�1bra�Ctz'1. V
16. Will return water re-enter the reservoir? (Check one) ❑Yes ❑No XNIA
(If Yes. specify point(s) of re-entry and show on Excavation Area Drawing)
17. Is there an existing facility (e.g. pier) that access is being maintained to by conducting the
excavation? ❑Yes J io New c j *j be emdrucked Sec 4 k c he D w1'n 5 4
(If Yes, provide the existin ermit number. IfSD, include a scaled drawi g of the pr Qposed
facility). Permit # Privq}e FiCi ��iie5 stru_c77or14pp1;ccc7rov
Exi or -A -1-obe,revYloved 4 rep 1 creed)
18. Total planned duration of -the work (Include first equipment mobilizatio , excavation
through final mitigation measures complete):
START 7 / j i FINISH 1 Z7
(Month) (Year) (Month) (Year)
Duke Energy
Excavation Program
Page 7 of 13 rev 10/1/2019

ication Form
Part II. (Continued)
B. Protection / Avoidanc
ca
-r
a3
CeS
rd
c0
a)
CC
etl
CJ
Ci
a
Cci
GA
a)
a)
r�
V
a
7
Identification
d
2
2
4
2
-z
e. Historic properties (specij)
a)
Cs]
1. Rare or threatened species (sped)
rev 10/1/2019
Co
cc
O.

u
•
Excavation Per
Duke Ener
Avoid (A) or Mitigate (M)
(**)
2
Work Area Dwg. I❑
Identification
''
2
Z
1L LI
Q�
Protection/Avoidance Areas
(check all that apply)
g. Buried gas, water, sewer,
communications or electric lines (circle)
h. Impact Minimization Zones as
identified by Duke Energy
i. Other areas requiring specific
avoidance, protection or mitigation (specify)
List and attach mitigation plans

Duke Energy Excavation Permit Application Form
C. Applicant's Signatures
Comments:
Applicant Name (print) rot. ��L�s
Applicant Signature*
Co -Applicant Name (print)
Co -Applicant Signature*
Co -Applicant Name (print)
Co -Applicant Signature*
Co -Applicant Name (print)
Date 5-3 I
Date
Date
Co -Applicant Signature* Date
Co -Applicant Name (print)
Co -Applicant Signature* Date
*Per my signature, the information provided in this application is correct to the best of my
knowledge.
Duke Energy
Excavation Program
Page 10 of 13 rev 1o/1/2019

Duke Energy Excavation Permit Application Form
Part III. Additional Information
y
Deed and Survey Plat: A copy of the deed and registered survey plat or other instrument
under which each applicant and co -applicant claims title to the affected property (the
shoreline adjoining the excavation area. equipment staging area, area crossed by any spoil
and return water lines, and the disposal area). If the applicant(s) is(are) not the owner(s) of
said property, then forward a copy of the deed and registered survey plat or other instrument
under which the owner(s) claim title plus written authorization from the owner(s) to carry
out the project on their land.
Excavation Area Drawing: An accurate drawing of the area to be excavated. The drawing
must show at a minimum, a North arrow; the boundaries and acreage of the proposed
excavation area and equipment staging areas; lake, county, city, cove, tributary, road and
subdivision names and lot numbers (as applicable); property corners for project front lots;
the full pond elevation contour and lines dividing the cove width into equal thirds (as
applicable); approximate volume in cubic yards of the material to be excavated; point(s) of
return water re-entry; the boundaries of any adjoining areas that are to be specifically
avoided or protected during the work and the location (address) of the disposal area for the
excavated material. [NOTE: A copy of this drawing must also be provided to the
excavation contractor to ensure restricted areas are not impacted.]
Disposal Area Drawing: An accurate drawing of the proposed design for the disposal area.
The drawing must show at a minimum, a North arrow; the boundaries and acreage of the
proposed disposal area; lake, county, city, cove, tributary, road and subdivision names and
lot numbers (as applicable); the full pond elevation contour (unless disposal is well away
from the lake); the boundaries of any adjoining areas that are to be specifically avoided or
protected during the work; the location (address) of the excavation area from which the
material came and a statement of the disposal area's capacity with all dimensions labeled
that were used in the volume calculation. [NOTE: A copy of this drawing must also be
provided to the excavation contractor to ensure restricted areas are not impacted.]
Also note for projects larger than one (1) acre in North Carolina. including excavated.
equipment staging, and disposal areas, you must submit an erosion control plan. For
projects larger than two (2) acres in South Carolina, including excavated, equipment staging
and disposal areas, you must submit an erosion control plan. For projects < two (2) acres in
South Carolina, you must submit a completed standard reporting form for construction sites
disturbing two (2) acres or less to the South Carolina Dept. of Health and Environmental
Control (SCDHEC) Stormwater Management
Vicinity Map and Driving Directions: A vicinity map and directions by road showing
directions to both the excavation area and disposal area. Include the latitude and longitude of
both the excavation area and the disposal area.
Part IV. Agency Reviews and Approvals
Begin this section with a summary table of all agencies consulted and applicant response to
agency comments as shown in the example table below. Agencies should be listed in the order
Duke Energy Page 11 of 13 rev 10/1/2019
Excavation Program

Duke Energy ExcaN ation Permit Application Form
shown in the Agency/Organization List. Consultation letters must be dated within the two years
preceding Duke Energy's receipt of the application.
Table IV-1. Sample Agency Comment and Response Table
Agency Comment f
Agency 1
The activity is approved as proposed.
Agency 2
The on -site well provides drinking water to the
public. Please contact Mr. Smith to discuss the
proposed changes and potential issues
associated with your proposal.
You must contact us immediately if
endangered species are located during the
course of construction.
Agency 3
Requested agency comments on 1/1/20xx and
again on 2/1/20xx. No response as of
2/1 6/20xx.
Agency 4
Section 401 Water Quality Certification
NA
Applicant Response
Contacted Mr. Smith on 111/20xx. No
further action needed.
Applicant will contact Agency 2 if
endangered species are located during
construction
NA
Applicant will comply with the conditions of
the 401 Water Quality Certification
Following the table of agency comments and applicant responses, include a table of permits and
certifications issued by the reviewing agencies. As with the table of agency comments and
applicant responses, agencies should be listed in the same order as they are listed in the
Agency/Organization List.
Table IV-2. Sam le A en
Agency
Agency 1
Agency 2
Permits and Certifications Table
Permit/Certification Name
Surface Water Withdrawal Permit
Section 401 Water Quality Certification
Date of
Issuance
Date of
Ex i 'ration
Following the two summary tables, include a copy of all correspondence to and from any local,
regional, state and federal agencies or other organizations with which you are required to consult,
including any required permits (e.g.. Section 401 water quality certifications, Section 404
dredge/fill permits, building permits, etc.) or other approvals or comments which have been
obtained from these organizations regarding this activity. Include a copy of any local, regional,
state or federal regulations or guidelines that will be followed. All permitting issues must be
resolved and clearly documented. Correspondence should be organized in the order the agencies
are listed on the Agency/Organization list with the applicant's request for comments followed by
additional correspondence in chronological order. All permits must be valid at time of
Duke Energy
Excavation Program
Page 12 of 13 rev 10/1/2019

Duke Energy Excavation Permit Application Form
application and have a term longer than the projected schedule for completing the permitted
project.
Part V. Additional information
Provide relevant additional information. Reference previous parts as applicable. Include the
FERC-required Environmental Assessment if you were directed to do so during the initial site
visit. If there are co -applicants, this is where their information would be provided (see Part I).
Duke Energy
Excavation Program
Page 13 of 13 rev 10/1/2019

Type: CONSOLIDATED REAL PROPERTY
Recorded: 10/2/2020 1:43:20 PM
Fee Amt: $1,126.00 Page 1 of 4
Revenue Tax: $1,100.00
Iredell County, NC
Ronald N. Wyatt Register of Deeds
BK 2740 PG 1132 - 1135
NORTH CAROLINA GENERAL WARRANTY DEED
Excise Tax: $1,100.00
Tax Map Parcel Identifier No.: 4627614803.000 & 4627613061.000
Mail to: Andrew J. Abramson, 225 N Main Street, Suite 200, Salisbury, NC 28144
This instrument prepared by: Andrew J. Abramson, a licensed North Carolina
attorney. Delinquent taxes, if any, to be paid by the dosing attorney to the County
Tax Administrator upon disbursement of closing proceeds
THIS DEED, made this Pt day of October, 2020, by and between
CURTIS H. FOREMAN, widower
Whose mailing address is: 116 E. Brentwood Road, Greensboro, NC 27403
Hereinafter referred to as GRANTOR; and
BRET R. BUSBY and wife, SARAH P. BUSBY
Hereinafter referred to as GRANTEE,
Whose mailing address is: 5 Oak Road, Salisbury, NC 28144
The designation Grantor and Grantee as used herein shall include said parties,
their heirs, successors and assigns, and shall include singular, plural masculine,
feminine or neuter as required by context.
WITNESSETH, that the Grantor for a valuable consideration paid by the Grantee,
the receipt of which is hereby acknowledged, has and by these presents does grant,
bargain, sell and convey unto the Grantee in fee simple, all that certain lot or parcel
of land situated in the County of Iredell, North Carolina, and more particularly
described as follows:
See attached Exhibits "A" and "B" for legal description.
The property herein described was acquired by Grantor by instrument
recorded in Deed Book 633, Page 987, and Deed Book 633, Page 977, Iredell County
Registry.
The Property Conveyed hereby is/ X is not the primary
residence of the Grantors.
submitted electronically by "The woodson Law Firm"
in compliance with North Carolina statutes governing recordable documents
and the terms of the submitter agreement with the Iredell county Register of Deeds.

TO HAVE AND TO HOLD the aforesaid lot or parcel of land and all privileges
and appurtenances thereto belonging to the Grantee in fee simple.
And the Grantor covenants with the Grantee, that Grantor is seized of the premises
in fee simple, has the right to convey the same in fee simple, that title is marketable
and free and clear of all encumbrances, and that Grantor will warrant and defend the
title against the lawful claims of all persons whomsoever except for the exceptions
herein after stated.
Title to the property hereinabove described is subject to the following exceptions:
Easements, conditions, restrictions of record and the Ad Valorem property taxes for
the current year.
IN WITNESS WHEREOF, the Grantor has duly executed the foregoing as of the day
and year first above written.
citurtis. For an
STATE OF NORTH C ROLINA
(SEAL)
COUNTY OF ROWAN
1, 0.510_ . S %CiSSIDn , a Notary Public of CLO}L
County and aforesaid State, do hereby certify that Curtis H. Foreman personally
appeared before me this day, and acknowledged the due execution of the foregoing
instrument.
WITNESS my hand and Notarial seal, this day of October, 2020.
My commission expires:
(SEAL)
NOTARY PUBLIC
LESLIE H JACKSON
Votary Puol,c, North C6firAna
Dave County
MyCammis ,on Expires

EXHIBIT "A"
Tract 1 (Parcel 4627614803.000):
BEING Lot 443 in Section 8, as shown on map recorded in Map Book 13 at Page 78, in the
Office of the Register of Deeds for Iredell County and being pant of the property conveyed to
Crescent Land & Timber Corp. by deed of Duke Power Company recorded in Book 481 at
Page 91, in the Office of the Register of Deeds for said county.
Tract 2 (Parce14627613061.000):
That tract containing 0.20 acre as it is shown on nzap of Grantor dated February 9, 1978
marked Mountain Island, ale No. 1168 a copy of which is attached as Exhibit 'B" and
incorporated herein for further reference.
Being the same property conveyed to Curtis H. Forman and wife, Jean B. Foreman as
described in Deed recorded in Book 633, Page 987, Rowan County Registry. Said description
being incorporated herein for further reference.

EK11IBIT "B"
This map may not be a certified survey and has not been reviewed by a local
government agency for compliance with any applicable land development
regulations and has not been reviewed for compliance with recording
requirements for plats.
•
.,.•.tip,
LOT 433
414 4.36'i
n + 274,t'
SECTION 8
LOT 438
"` AR E A =
0.20 ACRE
ti
CRESCENT LA NO a TIMBER CORR
{ OAVENFQRT COLLEGE
U_M,i. -6'1-A
pi
Bp'

‘50
n
' iI3 'ai3dd01-G5tral�
Q
z
W
a
rr
C7
2
f+7
0
a r
d �a
CD 03
cn- `t
rn
co-4D N b°
- -1
Ylz
:,0
co
C1
PC_
E ` rn r
rn
zn�rn
0RL,z
Cr
f.
c Ln
{ C C)
W
wN
111
-i
\\c �
\
\ 7'
" '
0
a
0
z
7-
0
19? '311;r153OLMV
NO00 Old
3102{Ic 213ddo1-155 N9
EZE I I -Ot•LZ
co
03rnC
a
Z
NYW ON J V1
fl
0

Custom Dock & Lift
Systems, Inc.
NC General License Contractor # 49723
1156 Perth Road
Troutman, NC 28166
704.528-7400 Phone
704-528-3400 Fax
Sarah Busby
321 Grasshopper CIR
Mooresville, NC 28117
SUMMARY
4/22/21
DESCRIPTION
1) Dredge approximately 250 cubic yards with ail required slopes at full pond.
a. Dredge material to be hauled off site
1

■4
z
4
WI- '(�
:3 1— 2 r —
4 N� oQ2m
3P',6 sf
N i j:
:14
LAKE
l Ic-FNfpE NIJMBCR L-3934
62R-443•i92a
0drJ �° \r
y,
°mod
� b/� s‘
N.
YS) N.
M
u1
1
0. n tO
DJ
mNIL
U
x 3' O K
c —} a
0.
OF
zt
a n,
ca
0
z
U
Cd
N
U
C4,

45-7
f rri
/ rr,
MACE
OIL
4-
Atcatt
J

A
co
'Cr 03
=Z
ti
te
Cr9N
CI
CD 0
-.
I
Ira
•

DUKE ENERGY DIRECTIONS BY ROAD FORM
Lake Use Permit Applicants and Contractors: Ease of locating the proposed project
site canhave a big impact on permitting processing time. Please complete this form and
return it along with your completed application to:
DUKE ENERGY
C/O LAKE SERVICES —EC 12 Q
526 SOUTH CHURCH STREET
CHARLOTTE, NC 28202
Applicant's Name: Sarah Busby
Street Address (at lake): 321 Grasshopper Lane Mooresville, NC 28117
Lake Name: Norman
Subdivision Name: Crescent Land & Timber Corp.
Property Section: 8 Lot #: 443
City: Mooresville
State: NC
Telephone: [phone]
County: Iredell
Zip: 28117
Directions (from major road or highway):
From I-77 NB, Exit 35, Turn Left onto Brawley School Road, Turn
right onto McKendree Road, Turn Right onto Grasshopper Circle.
Keep Right at the "Y" and travel approximately to halfway point of
circle. Property will be on the right.
Descriptive Structure(s) on Property (i.c. brick gat -age, white fence, mobile
home, etc.)
*Note: Please use the back of this form if desired to draw us a map to the site.

D
CU
Address or Place
321 Grasshopper Circle Mooresville, NC 28117
Home )7 Find Latitude and Longitude
Ads by Google
r•
A
Stop seeing this ad
0
■
Decimal Degrees Latitude:
Decimal Degrees Longitude: -80.929176
Show Paint
N
N

D UIE ENERGY DIRECTIONS BY ROAD FORM
LANCASTER CUSTOM DOCKS DISPOSAL SITE
Lake Use Permit Applicants and Contractors: Ease of locating the proposed project
site canhavea big impact on permitting processing time. Please complete this form and
return it along with your completed application to:
DUKE ENERGY
C/O LAKE SERVICES — EC 12 Q
526 SOUTH CHURCH STREET
CHARLOTTE, NC 28202
Applicant's Name: Lancaster Custom Dock Disposal Site
Street Address (at lake): 1162 River Highway Mooresville, NC 28117
Lake Name: Norman
Subdivision Name: Big Daddy's of Lake Norman
Property Section: Lot #: 2
City: Mooresville County: Iredell
State: NC Zip: 28117
Telephone: [phone]
Directions (from major road or highway): From I-77 NB, Exit 36, Left onto NC-
150 WB, Disposal Area is on the right behind Big Daddy's Restaurant
Complex.
Descriptive Structure(s) on Property (i.e. brick garage, white fence, mobile
home, etc.)
*Note: Please use the hack of this form if desired to draw us a map to the site.

1 .-8n-(.0!} OHd U1
Y91BL 'PM '4MWlO Lt '019tl
KLH d
FLOOR JOIST ALLOWABLE SPANS
GENERAL NOTES
it n
TE CIIN ZW 31q�}dp'♦1'
7.7424 E .at MMS 3l6
servjs woe
ROOF RAFTER ALLOWABLE SPANS
-i
fa g
w
Eo
Ewe
xa
rfa
spwEs
zNe
Pgg
4,aa
rvoudups�a �w
MiP
�a a3 fkr•
Lot wwe 02
r ulcer
t ;AA
Nit
371J5 �
DRIP PAN NOTES
HANDRAIL NOTES
NOTE: ANY DEVIATION FROM THE PLAN MUST BE APPROVED BY DARDEN ENGINEERING SERVICES, LLC

We-gm-0..] 3I04a13L
9uII '31 'xnunmu veva .UrD. 9CI
aria ar 71sis31nx
da aaurunac ra'
Z%0 6 i
IN
mourn.. 1851I13 HMYS
31B
J3 1131081dY
ki/Lli Y AA3ai'
S d/� 6 ;
ICI
P
IJ
NW1dg
WALKWAY PLAN VIEW LAYOUT
31YQ
Aga
A ,l = .f1f
3 M.G
ti
CN
H4LKHAY ISOMETRIC LAYOUT

OO L..9ES-[ra1 3Noijdnak
•area' It .proNWu'mw *Wad 9S<<
arm we IThW9 a.
r.ror
411iYttA1 AEISM INNS
0e
AB 03WPkN
I tln AU71B V AAA'
:31111 -41 HMYtl7
1✓Dlldfh9537
3EV0
Fay
.��1 • .}IC
o
PILE do CROSSHEAD PLAN VIEW LAYOUT
n
N
0
g

vvre-azs-Irsz) 311:41drI31
8919E '7X '1l Ilneel 'OVRI ROI 941I
- Lr.r
1
JI
PI
II
Mgr ar 2sewmr
4 gRAvNms frr
!ON AVIS
3Ib
rn nvi AGSM Holes
3nl
v¢ G3,0aa6v
4411d X30 :
A7y
1111111
1111
EAST aEk,4TION
atas
71Y17
AMU Y ACEEM
A9 NMI]
gla
k n

uurc-accdwL) 7NOMPai
vv=aa •i •rmunwu'moe FLROINNLI
elm?5r 2.r
45611=.69 rar
ase Mes
varim Virus
7114
.0 ELVONcldi
ltI:lr firma v .1.1132Br
laa ) MLwPa
Nouelfii37
Siva
OP
.o-.� =.�IrTKIS
..
O
0
L
�
O
p
r
L
+�
1
al
it
1I
IIIIIIII[
iing
ll�.,,,,...�i
. 't
..\ 1
Ia
R
r—
Lo
N

Onrl-625-0N!] 3NOH1:011
BF Iee 'MH 'NNr rss '+inky NW3d ss11
WINN ARA HMrS
Al 0310434?
oxhlr order .U13FQ'
aim a tow
• .FIE
3M£
m
cdn
m
b
0
p
I1 V7

r

DWR Pre -Filing Meeting Request Form
ID#*
Regional Office *
Reviewer List*
20210686
Version*
1
Mooresville Regional Office - [phone]
Alan Johnson
Pre -Filing Meeting Request submitted 4/2/2021
Contact Name * Donna P. Hrko
Contact Email Address* [e-mail]
Project Name * Busby Dredge and Shoreline Refresh
Project Owner* Sarah P. Busby
Project County* Iredell
Owner Address: Street Address
Sarah Busby
Address Line 2
321 Grasshopper Circle
City State / Rovince / Region
Mooresville NC
Fbstal / Zip Code Country
28117 USA
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
W 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.*
Dredge area for boat slip access. Shoreline refresh for stabilization
and erosion control.
Please give a couple of dates you are available for a meeting.

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 4/2/2021