20210715 Ver 1_Shoreline Stabilization_20210623

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:
MierzejewskiFinaIDWQPreliminary.pdf 424.4KB
Pre -fling Meeting or Request Date 4/12/2021
ID# 20210715 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 * [e-mail]
Rease provide an err -ail address for payment and requests for pure infornation here.
Owner Information:
Name: * Samuel N ierzejewski
Email: * [e-mail]
Phone Number:* [phone]
(xxx)xxx-xxxx
Mailing Address:* Street Address
1422 Club View Dr
Address Line 2
City
State / Frovince / Region
Grove City
OH
Fbstal / Zip Code
Country
43123-7622
US

Is there an agent working on the
project? *
Agent/Consultant Information
.................................................................................................................
Name:
Company Affiliation:*
Email:
Phone Number:*
Mailing Address:*
F Yes
r No
Mandy Renegar
Renegar Construction
mandyrenegarrealestate@gmaiL com
[phone]
(XXX)XXX-XXXX
Address
6026 Hwy 150 E
Address Line 2
City
Denver
Fbstal / Zip Code
28037
Asigned and dated copyof the Agent Authorization letter:*
137SkippersCoveAgentform.pdf 253.03KB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:* Sam Shoreline
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:*
Latitude:* 35.663253
Street Address
137 Skippers Cove Lane
Address Line 2
city
Troutman
Fbstal / Zip Code
28166-7615
State / Province / Region
NC
Country
US
Longitude:*-80.899407
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*
137DWQDrawingFina1REvised.pdf 731.39KB
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.)*
13 7SkippersCovePic s Scanned. pdf 1.62MB
4. Location of the property (where work is to be conducted)
Nearest Town:* Troutman
County:* Iredell
Lake/ river/ ocean adjacent to Norman
property:
Subdivisions name or site address:* 137 Skippers Cove Ln Troutman, NC 28166
Include phasellot nunber
Directions to site:*
From Mooresville
NW on W McLelland Ave, left onto NC-150/B Plaza Dr. to US-21 N/
Charlotte Hwy, Lft onto Cornelius Rd, Rt onto Judas Rd, Rt onto Perth
Rd, Sharp lft onto State Park Rd, lft onto Honeycutt Rd, lft onto
Tremount Ln, Rt onto Skippers Cove Ln
Rease include road narres and nunbers, landnarks etc.
5. Describe the existing land use or condition of the site at the time of this application:*
Residential
Fbsidential, undeveloped, etc.
6. Property Size .29 acres
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
Put Rip Rap along 8 V of shoreline to prevent erosion and provide
stabilization
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, back fill, excavation, rip rap, retaining walls, etc.)
324 Sq Ft
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.)
81 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:*
(nurrber of trees, for instance)
none
Sketch: 137SkippersCoveDWQSketchandInfoRevise... 1.76MB
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:* Samuel Mierzejewski
Signature:

Initial Review
Is this accepted into the review
process?*
Project Number:* 20210715
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: 4. ] PLAN NO:
STREET ADDRESS:
Tease print:
-Property Owner:
Property Owner•.
Meg -2e
,a
� 'ttr� � i
PARCEL ID:
K'k
The undersigned, registered property owners of the above noted property, do herebyauthorize
4aj�
lcontrcto
J (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of this
-ermit or certification and any and all standard and special conditions attached.
Property Owners Address (if different than property above:-
c,i
Telephone:
We hereby certify the above information submitted in this application is true and accurate tothe
nest of our knowledge.
it
uthorized Signature
Date

K
; State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL DUALITY FORM: SSG 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
i
Lake
(At Full Pond/ Normal Water Levels
I
�1
Full Pond/ Nor vep
l �
Plea Vier
FORM: SSGP 02-2017 Page 1 of 3

C
Side View CL
Lake
(A1 Full Pond/ Normal 4Yater L.-Ij Existing Dock
30 ft 7ft
3 ftx 151)h
Pull Pond/ Normal Water Level Below full pond/ N WL
a r`r 7 �
Slloreiln4hx 150ft
Riprap Above full pond/ N WL
Z ft. x 150k _
additional clearing
`i%necessary
E. AMPLE
Plan View
FORM: SSGP 02-2017 Page 2 of 3

Mmsy
��x
m
R �
s$
�L
P
as
� n+.a.ry�,r4 i
B R'-
C
alb
fr.1OmP
zxa�
O
N
� O
v p
C
V
A
-
-1
a
0
a
w
>
-•
m
�
w
p
�
31
o
y
y� e
^yp �
� N Og i9 P
nuslRiG .yy pPoyA]E ~
AN
O
�'t
+Y S
r- .�
�• �1-0
L6 � b O1
z m
�r
Op9n�
�141
y�
"+
m$Nm2
S i5,
iC
5�
�
d
I
om
�180
lx f'CL�
O
Nz l 1 I I
t'i i i6 zla�i 1 1
AWN d A
wi
m Moto Is��o�
£ < � IN
T
e
�e
PLAT WOK 115, PAGE 23
S&I

k6del! bounty
J
Iredell
Prinijed April 08, 2021
See bellow for Disclaimer
� 1
I
i
i
1 k i 222
I i 218
f
to maps prepared for this website are generated from recorded deeds, plats, and other public retards. Users of these maps are hereby notified that the information
ovided 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
ry of this information is at their own risk. All maps on this site were prepared using a 1000AFm Grid based upon the North Carolina State Plane Caordinate System from
e 1983 North American Datum. The delinquent real property tax overlay is updated monthly. The information presented is not intended to be used oij relied upon a
ficial notice of tax liens. For additional information regarding delinquent taxes, contact the Iredell County Tax Collector's Office.

,fPCONNECTGIS
web reasr�•tc.
JPW
fredell
Printed April 08, 2021
See Belew for Disclaimer
maps prepared for this wehs'rte are generated from recorded deeds, plats, and other public records- Users of these maps are hereby notified that the mlormation provided herein sho Id be verified. Iredell County assumes
aI responsibilities for any of the information contained on thks site_ Users are advised that the use of any of this information is at their own risk. All maps on this site were prepared usi g a 10005€'" Grid based upon the No
olina State Plane Coordinate System from the I M Nordr 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
liens. For additional information regarding delinquent taxes, contact the Iredell County Tax f nllartnr<rxf—

OCOINNEC-TiGIS
k
a
7C?
7
ra
Iredel!
Prin ed April 08, 2021
See &el w for Disclaimer
i : 43 FE

rj bing rnaps
A Mooresville, NC
B 137 Skippers Cove Ln, Troutman, NC 28166
Mooresville, NC
i
Head northwest on W McLelland Ave toward S Academy St
2
Bear left onto NC-150 / E Plaza Dr
ry
Take the ramp on the right
3.
Citgo on the corner
4
Keep straight to get onto ramp
S
Keep straight to get onto ramp
'
6
Merge onto US-21 N / Charlotte Hwy
7
Turn left onto Cornelius Rd
f>
g
Turn right onto Judas Rd
I >
g
Turn right onto Perth Rd
10
Take a sharp left onto State Park Rd
11.
Turn left onto Honeycutt Rd
12
Turn left onto Tremount Ln
r>
13
Turn right onto Skippers Cove Ln
Arrive at Skippers Cove Ln
14.
The last intersection before your destination is Tremount Ln
22 min, 12.0 miles
Light traffic
Via Cornelius Rd, Perth Rd
.9 mi
_5 mi
2189 ft
12ft
207 ft
1.9 mi
24 mi
12 mi
3 0 mi
1 1 mi
0.6 mi

137 Skippers Cove Ln, Troutman, NC 28166
These directions are subject to the Microsoft® Service Agreement and are for informational purposes only. No guarantee is made regarding their Completeness or accuracy.
Construction projects, traffic, or other events may cause actual conditions to differ from these results. Map and traffic data © 2021 TomTorn.

ID#* 20210715 Version* 1
Regional Office * Mooresville Regional Office - [phone]
Reviewer List* Alan Johnson
Pre -Filing Meeting Request submitted 4/8/2021
...... _- -
Contact Name* Mandy Renegar
Contact Email Address*
Project Name*
Project Owner*
Project County*
Owner Address:
[e-mail]
Sam Shoreline
Samuel Mierzejewski
Iredell
Stroet Aidress
137 Skippers Cove
Address Line 2
cfty
Troutman
Rrstal 1 Zip Cade
28166
Is this a transportation project?* i Yes {' No
State I F roonce I Fbgion
NC
Cw-ky
United States
Type(s) of approval sought from the DWR:
F 401 Water Quality Certification - r 401 Water Quality Certification -
Regular Express
Individual Permit r- Modification
17 Shoreline Stabilization
Does this project have an existing project ID#?*
r Yes (-- No
Do you know the name of the staff member you would like to request a meeting with?
Alan Johnson
Please give a brief project description below and include location information.
Want to put new Rip Rap along shoreline to prevent erosion
See attached road directions to property
Please give a couple of dates you are available for a meeting.

4/12/2021
4114/2021
Please attach the documentation you would like to have the meeting about.
SamMlnfoPack DtilWQrevised.pdf 2.16MS
Ud ordV
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.
d 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
e�7dfi%Cfif i�/�!f�'�.7Y�t3Y#l.C-f
Submittal Date 4/812021