20211723 Ver 1_Shoreline Stabilization_20211130

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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 QUALITY FORM: SSGP 02-2017
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.)
Karen Higgins Karen Higgins
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
lik
A. Applicant Information [15A NCAC 02H .0502(a)] CF/`,
1. Owner Information 4/
Name: Ch/(\S Ca►rn be I I
Mailing Address: P.O b t <90<9
MthCi n r , INUd 2130 2 yelp,h,-i3o-116,1 Fax Number: so
Telephone Number: m�h Q6mgIQCfricl l 1 °i t/III.com �9�)/N`9
E-mail Address: 9 O
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/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf) •
Name: CorN Dc1vIS
Company Affiliation: (OVQy DOIYIS ConctruC�-IOI(), INC
Mailing Address: 1111 s'SS1 ' Dante' Rri
KOXhO '(), Al c 275-74 Telephone Number: 33to 503- 732o ,Lax Number: HO-5c -5295
E-mail Address: COPtki PCf ay IS(a)_@rria, 1 . corn
B. Project Information [15A NCAC 02H .0502(a) & (b)]
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.
FORM:SSGP 02-2017 Page 1 of 3

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 propertyA (where work is to be conducted)
County: V,Q,6 n Nearest Town: S(MOM
Lake/river/ocean adjacent to property: 1k .O La !'L
Property size (acres): 1.2 G,Cre `Subdivision name or site address(include phase/lot number): The Rece. rve. '
Lo 1- At(o
Directions to site-please include road names and numbers, landmarks,etc.:
�t down Seam �d unfi I you o of to Zion Le ire I Church
e urn rib h+ oh Zion Level Church `2i J- i-Ya,ll I -For . . 7 mile'.
Tulin t-eft- on PMeSboro h Ect t-eS Rd. in •g miles furs !effon
ES1-�fi� art . In .� ii► . r�eVHrv11ion 61'11 be on your left.
Latitude(in decimal degrees) 71.0 72, Longitude(decimal degrees) 3V `JU 7
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped,etc.): (1ndeYQ lore d
6. Describe proposed work(include discussion as to how hardening of shoreline has been
avoided, or why it is necessary):
t-o rQ�Gir curren4-,4- cont-rol am' -Fa i-ure tram ot- Shore bile.
7. Will work be conducted from land? ® From water? ❑
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: _
230 -FI% of rip rap
Temporary impacts in square feet:
NIlk
9. Total amount of impacts above the normal pool lake level/Normal Water Level and 50 feet
land-ward rr
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet: 23o T t
Q� t ' Card
Temporary impacts (temporary clearing, construction corridor) in square feet:
NIA
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):
1\10 61( on oN ti- Nan rafS brUSh S build b e
I rnta ct-d .
FORM:SSGP 02-2017 Page 2 of 5

11. Signa e
Owner/Agent's Signature' [15A NCAC 02H .0502(f)] 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
Lake
(At Full Pond/Normal Water Level)
60L 2h° t
3�� l
ondI
i ����i.i� �►ys���r. ,n
OrgininOrdir
Full Pond/ Normal Water Level i"I`iiil0I iv//III
Shoreline 00000 4.0.0' ArIP.Pf0Pooraiii.
No adds t io1i1Ct •: iw %►I°io ��—��� Lift x
o
ofavon9 would be 4-W
re _rvit
Pond/
4/fro
Plan View
OW 00 = Car iSbzl
FORM:SSGP 02-2017 S-eler)OrA MC Page 3 of 5
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Google Maps Semora Road, North Carolina to 711 Estate Road, Semora, NC Drive 9.1 miles, 12 min
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Map data©2021 Google 1 mi .
Semora Rd
t 1. Head northwest on NC-57 N toward Concord Ceffo
Rd
rr 2. Turn right onto Zion Level Church Rd
9/nP
41 3. Turn left onto Pinesborough Estates Rd
..1 4. Turn left onto Estate Rd
711 Estate Rd
Semora,NC 27343
These directions are for planning purposes only.
You may find that construction projects,traffic,
weather,or other events may cause conditions to
differ from the map results,and you should plan
your route accordingly.You must obey all signs or
notices regarding your route.

DWR Pre-Filing Meeting Request Form
NORTH CAROLINA
EnWonnrnfd Quality
Contact Name* Corey E. Davis
Contact Email Address* [e-mail]
Project Owner* Chris Campbell
Project Name* The Reserve-Lot#6
Project County* Person
Owner Address:* Street Address
711 Estate Rd
Address Line 2
City State/Province I Region
Semora,NC North Carolina
Postal/Zip Code Country
27343 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-
Regular Express
Individual Permit Modification
Shoreline Stabilization
Does this project have an existing project ID#?*
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.*
Repairing an eroding Shoreline.
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'
Submittal Date 10/19/2021