20211666 Ver 1_Shoreline Stabilization_20211117

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ROY COOPER gl .. ;7's
Governor
. . .
MICHAEL S.REGAN �
Secretary
S.DANIEL SMITH NORTH CAROLINA
Director Environmental Quality State of North Carolina
Department of Environment Quality
Division of Water Resources
15A NCAC 02H.0500—Water Quality Certification,Shoreline Stabilization
FORM: SSGP 09-2020
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent to:
If sending via US Postal Service If sending via delivery service(UPS, FedEx, etc.)
Paul Wojoski Paul Wojoski
DWR—401 & Buffer Permitting Branch DWR—401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604
NOTE: 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)which states "At least 30
days prior to submitting a certification request, the project proponent shall request a pre-filing
meeting with the certifying agency." In accordance with 40 C.F.R. Section 121.5(b)(7), and (c)(5), all
certification requests must 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 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 to this application.
Date of Pre-filing Meeting Request: I / (required)
DWR ID# Version.�. (if applicable)
A. Applicant Information [15A NCAC 02H .05021a ]
1. Owner Information
Name: 7 3 key ¢re r/I„t S / --
Mailing Address: 7d,5'42 Llor t2i‘nt ;,/ _;-,>
r /k4 et--' ,.1--'' .
Telephone Number: "0 -93 7;e)5' S' Fax Number:
E-mail Address: ja '5 /to' +' /!'A.I47r..,,.ito. C 00. -'
North Carolina Department of Environmental Quality I Divisions of Water Resources
512 North Salisbury Start 1617 Mall Service Center I Raleigh,North Carolina 27699-1617
,,..4, . .4.' °ice' 419.707.91100

DWR Pre-Filing Meeting Request Form
444,4-
NORTH C:AROLINA
A vhwmrnwlQualRy
Contact Name* David Chambless
Contact Email Address* [e-mail]
Project Owner* David Chambless
Project Name* Bella Vista Lake Glenville Seawall
Project County* Jackson
Owner Address:* Street Address
373 Lake Shore Dr.
Address Line 2
City State/Province/Region
Cullowhee NC
Postal I Zip Code Country
28723 United States
Is this a transportation project?* Yes - No
Type(s)of approval sought from the DWR:
401 Water Quality Certification- 401 Water Quality Certification- RECEIVED
Regular Express
Individual Permit Modification
Shoreline Stabilization NO\I 1 -1 2021
Does this project have an existing project ID#?*
Yes No DEQ WATER RESOURCES
MITriNQ
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.* 401 &BUFFER PER
We will be constructing a seawall at the lakes edge at the bottom of
my clients property.We will not be using and large equipment.This will
all be done by hand.
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.

Signature*
PIA'°eel"'
Submittal Date 10/22/2021

11/12/21,12:50 PM New Submission
Shoreline Stabilization Application Form
—N Water Resources
ENVIRONMENTAL QUALITY
15A NCAC 02H :0500—Water Quality Certification,Shoreline Stabilization
FORM:SSGP 10-2013
DRAFT-NOT FOR USE AT THIS TIME
I.Applicant Information II. Project Information Sign and Submit
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]
Please provide an email address for payment and requests for more information here.
Owner Information:
Name:* Jason Nau
Email:* [e-mail]
Phone Number:* [phone]
(xxx)xxx-xxxx
Mailing Address:* Street Address
2050 Capital Circle NE.
Address Line 2
City State/Province/Region
Tallahassee FL
Postal/Zip Code Country
32308 United States
Click to add another owner
Is there an agent working on the project?* 0 Yes
0 No
https://edocs.deq.nc.gov/Forms/Shoreline_Stabilization 1/2

11/12/21,12:50 PM New Submission
Agent/Consultant information
Name:* David Chambless
Company Affiliation:* Owner of Bella Vista
Email:* [e-mail]
Phone Number:* [phone]
(xxx)xxx-xxxx
Mailing Address:* Street Address
PO Box 1418
Address Line 2
City State/Province/Region
Cashiers NC
Postal/Zip Code Country
28717 United States
A signed and dated copy of the Agent Authorization letter:*
Upload
pdf only
Link to: (http://http://edocs.deq.nc.gov/WaterResources/0/doc/400417/Pagel.aspx)Sample Agent Authorization Form
(http://edocs.deq.nc.gov/WaterResources/0/edoc/459507/SAMPLE_AG ENT_AUTHORIZATION_FORM%20(2).docx)
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Save as Draft
https://edocs.deq.nc.gov/Forms/Shoreline_Stabilization 2/2

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 2 av47e f4U' PLAN NO. PARCEL ID: 7.5 h "0 7- Z'/)
STREET ADDRESS: ' Olcr l
Please print: / 7 �J�, ,�,
Property Owner: /" hovc.' , . �,C 5 L 2 6" Zka-se-,
Property Owner: Mom dtJ.fw vit 4 4
The undersigned, registered property owners of the above noted property, do hereby authorize
d," ac,f i `9 ,of Teii4 61/577(
(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):
7-7/Z
Telephone: P.o 133 'r ? Z ?l
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
• Authorized Signature
Date: ./1 c 2oz/ Date: / / —

2. Agent/Contact Person Information
A signed and dated copy of the Agent Authorization letter must be attached if the Agent has
signed this application form. (A form can be downloaded here:
http://www.saw.usace.army.mil/Portals/S9/docs/reguiatoryjre;dots/Permits/SAMPLE AGENT AUTHORi2
ATION FORM.pdf)
Name: l,/c1 v, a L hckyv,.4 5
Company Affiliation: &// 1/;S fj "O _v er-
Mailing Address: po /j k f 1 S'
(,,,5h;tss /Yc ?1 7
Telephone Number: a)i ) ��rj-a `I O .0A Fax Number: 404
E-mail Address: 3 1/ V1s tr-icA vidcyc rc 't ,1 - co el .1
B. Project Information [15A NCAC 02H .0502(al & (bj
1. Attach 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.
2. Provide a detailed site plan showing property boundaries and proposed locations of
vegetation clearing, buildings, retaining walls, docks, impervious surfaces, rip rap, excavation
or dredging below Full Pond/Normal Water Level elevations, and construction access
corridors. You may use the diagram provided at the end of this application form.
3. Attach a photograph of the shoreline/buffer proposed to be stabilized. (Include a scale of
some sort-a yard stick, shovel handle, etc.)
4. Location of the property(where work is to be conducted)
County: t' r`t ,. Nearest Town: 1' 5iti
Lake/river/ocean adjacent to property: Xe 64',, aitY
Property size (acres): ,c).? Ac..
Subdivision name or site address(include phase/lot number): 77 6Q ee.r,40ce'
Directions to site - please include road names and numbers, landmarks,etc.:
JJott bra t2 i /ake5-Xe'
Latitude (in decimal degrees) Longitude(decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): jZc 5-i/-4774z( Ade
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): fe tut S bec4 ero$td,, d( 7Z' 3-4:7,.44e,
FORM:SSGP 09-2020 Page 2 of 6

7. Will work be conducted from land? From water? J
8. Total amount of impacts below the normal pool lake level/Normal Water Level
Permanent impacts(including all excavation, backfill, rip rap, retaining walls,etc.)in square feet:
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool lake level/Normal Water Level and 50 feet
land-ward
Permanent impacts(including back fill, excavation, rip rap, retaining walls,etc.)in square feet:
rGt rts;Ma- 11
Temporary impacts(temporary clearing,construction corridor) in square feet:
10. Please describe the vegetation above the normal pool lake level/Normal Water Level and 50
feet landward to be impacted(number of trees,for instance): Vega-nt
11. Signature
By signing below, 1, as the project proponent, certify to the following:
• The project proponent hereby certifies that all information contained herein is true,
accurate, and complete to the best of my knowledge and belief
• 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
Owner/Agent's Signature [15A NCAC 02H .0502(f)J Date
Agent's signature is valid only if an authorization letter from the owner is provided.
12. 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
FORM:SSGP 09-2020 Page 3 of 6

Lake
(At Fill Pond/Normal Water Level)
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Full Pond/ Normal Water Lure
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Plan View
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( (At Full Pond/tkanal Vattr WW1 Existing Dock
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one owes o ' se.3soe
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Plan View 3
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FORM:SSGP 09-2020 Page 4 of 6

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FORM:SSGP 09-2020
Page 5 of 6

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 2 Failledlic., PLAN NO. PARCEL ID: 75 h3 '"07
STREET ADDRESS: 7
a/(0 tscif
Please print: ,
Property Owner L° `" ho'<, fib' t.. C a .94
Property Owner: M 'ON,"R 4
The undersigned, registered property owners of the above noted property, do hereby authorize
ef, 1e`9$ ,of -* e/lr L 1
(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):
Zo..5" (Ittr ' cry /,/6e1a ,s 3c'..1e
Telephone: P5� 3 a 2 9'
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
uthorized Signature
Date: f< /e%° Z/Z/ Date: /4/7

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