20211779 Ver 1_Shoreline Stabilization_20211209

Shoreline Stabilization Application Form
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
DRAFT -NOT FOR USE AT THIS TIME
Submission Form
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*
Owner Information:
Name: *
Email:*
Phone Number:*
Mailing Address: *
[e-mail]
Please provide an email address for payment and requests for more information here.
Taylor Hagadorn
[e-mail]
[phone]
(xxx)xxx-xxxx
Street Address
5437 Rocky River Road
Address Line 2
City
Mt. Gilead
Postal / Zip Code
28128
Is there an agent working on the project?*
Yes
No
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:* 187 Russ Drive
State / Province / Region
NC
Country
USA
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: 187Russ_Vicinity.pdf 94.81KB

Latitude:*
35.232760
Longitude: *-80.057790
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*
187Russ_Site.pdf 253.1 KB
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.)*
187RussPhoto.pdf 521.28KB
4. Location of the property (where work is to be conducted)
Nearest Town: * Mt. Gilead
County: * Montgomery
Lake/ river/ ocean adjacent to Lake Tillery
property:
Subdivisions name or site address:*
187 Russ Drive within The Cove
Include phase/lot number
Directions to site: *
From NC-731, Norwood, NC
Head east on NC-731 E toward Lillys Bridge Rd
Turn left onto Lillys Bridge Rd
Turn right onto Russ Dr
Please include road names and numbers, landmarks etc.
5. Describe the existing land use or condition of the site at the time of this application: *
Residential See attached photo.
Residential, undeveloped, etc.
6. Property Size .686
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
New 800 Sq Ft boat dock and 100 ft rip rap shoreline.
8. How will the work be done?*
From Land
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.)
100
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.)
200
square feet

11. 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)
See attached photo.
Sketch: 187Russ_Site.pdf 253.1 KB
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
• $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:* JeffPage
Signature:
Submittal Date: 12/6/2021

Initial Review
Is this accepted into the review process?* Yes No
Project Number:* 20211779 Version:* 1
Select Reviewer: * Chad Turlington:eads\ccturlington
Select Reviewing Office: Fayetteville Regional Office - [phone]
Has payment been received? * No Payment Needed
Fee Received
• Need Fee - send electronic notification
What amount is owed?*
• $240.00
$570.00

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Above full pond/ NWL
EXAMPLE
Plan View
FORM: SSGP 09-2020
Page 4of6

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FORM: 55GP 09-2020
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(At Full Pond/ Normal Water Level)
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Plan View
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‘eildh
A&
— — — — — —
Full Pond/ Normal Water Level
�• nhareirne — —
tie x'so&
additional clearing
if neressary
Lake
jAi Full Pond/ NnrnG4 Water tevell
_r_.
Riprap
Existing Dock
30 h. 71t
3 h. 150ft
Below full pond/NWL
4he350h
Above full pond/ NWL
EXAMPLE
Plan View
FORM: SSGP 09-2020
Page 4of6