20211804 Ver 1_Shoreline Stabilization_20211208

SAW-2017-01903
Property Owner:
Address:
Telephone Number:
E-mail:
Size (acres)
Nearest Waterway
USGS HUC
U.S. ARMY CORPS OF ENGINEERS
WILMINGTON DISTRICT
Action Id. SAW-2017-01903 County: Person U.S.G.S. Quad: NC -Alton
NOTIFICATION OF JURISDICTIONAL DETERMINATION
Ewart and Marilynn Hodgins
1048 Crystal Forest Drive
Semora, NC 27343
336-234-0192
[e-mail]
_1
Hvco Lake
03010104
Property Owner: Gerald and Martha Pevehouse
Address: 1010 Crystal Forest Drive
Semora, NC 27343
E-mail: jerrypevea,earthlink.net
Nearest Town Roxboro
River Basin Roanoke
Coordinates Latitude: 36.514993
Longitude: -79.087727
Location description: The project area for the Pevehouse/Hodgins approved jurisdictional determination is situated south of
Crystal Forest Drive on the following property parcel PINs: 9070-01-46-0782.000 and 9070-01-36-9686.000. The project area is
located near Roxboro, Person County, North Carolina. The Project Area is shown as the bold purple boundary on the
attached sketch labeled "Waters of the US Sketch Map."
Indicate Which of the Following Apply:
A. Preliminary Determination
❑ There appear to be waters, including wetlands on the above described project area/property, that may be subject to Section 404
of the Clean Water Act (CWA)(33 USC § 1344) and/or Section 10 of the Rivers and Harbors Act (RHA) (33 USC § 403). The
waters, including wetlands have been delineated, and the delineation has been verified by the Corps to be sufficiently accurate
and reliable. The approximate boundaries of these waters are shown on the enclosed delineation map dated MAP DATE.
Therefore this preliminary jurisdiction determination may be used in the permit evaluation process, including determining
compensatory mitigation. For purposes of computation of impacts, compensatory mitigation requirements, and other resource
protection measures, a permit decision made on the basis of a preliminary JD will treat all waters and wetlands that would be
affected in any way by the permitted activity on the site as if they are jurisdictional waters of the U.S. This preliminary
determination is not an appealable action under the Regulatory Program Administrative Appeal Process (Reference 33 CFR Part
331). However, you may request an approved JD, which is an appealable action, by contacting the Corps district for further
instruction.
❑ There appear to be waters, including wetlands on the above described project area/property, that may be subject to Section 404
of the Clean Water Act (CWA)(33 USC § 1344) and/or Section 10 of the Rivers and Harbors Act (RHA) (33 USC § 403).
However, since the waters, including wetlands have not been properly delineated, this preliminary jurisdiction determination
may not be used in the permit evaluation process. Without a verified wetland delineation, this preliminary determination is
merely an effective presumption of CWA/RHA jurisdiction over all of the waters, including wetlands at the project area, which
is not sufficiently accurate and reliable to support an enforceable permit decision. We recommend that you have the waters,
including wetlands on your project area/property delineated. As the Corps may not be able to accomplish this wetland
delineation in a timely manner, you may wish to obtain a consultant to conduct a delineation that can be verified by the Corps.
B. Approved Determination
❑ There are Navigable Waters of the United States within the above described project area/property subject to the permit
requirements of Section 10 of the Rivers and Harbors Act (RHA) (33 USC § 403) and Section 404 of the Clean Water Act
(CWA)(33 USC § 1344). Unless there is a change in law or our published regulations, this determination may be relied upon for
a period not to exceed five years from the date of this notification.
® There are waters, including wetlands on the above described project area/property subject to the permit requirements of Section
404 of the Clean Water Act (CWA) (33 USC § 1344). Unless there is a change in the law or our published regulations, this
determination may be relied upon for a period not to exceed five years from the date of this notification.

SAW-2017-01903
❑ We recommend you have the waters, including wetlands on your project area/property delineated. As the Corps may not be
able to accomplish this wetland delineation in a timely manner, you may wish to obtain a consultant to conduct a delineation that
can be verified by the Corps.
® The waters, including wetlands on your project area/property have been delineated and the delineation has been verified by
the Corps. The approximate boundaries of these waters are shown on the enclosed "Waters of the US Sketch Map" dated
9/11/2017. If you wish to have the delineation surveyed, the Corps can review and verify the survey upon completion. Once
verified, this survey will provide an accurate depiction of all areas subject to CWA and/or RHA jurisdiction on your property
which, provided there is no change in the law or our published regulations, may be relied upon for a period not to exceed five
years.
❑ The waters, including wetlands have been delineated and surveyed and are accurately depicted on the plat signed by the
Corps Regulatory Official identified below on _. Unless there is a change in the law or our published regulations, this
determination may be relied upon for a period not to exceed five years from the date of this notification.
❑ There are no waters of the U.S., to include wetlands, present on the above described project area/property which are subject to the
permit requirements of Section 404 of the Clean Water Act (33 USC 1344). Unless there is a change in the law or our published
regulations, this determination may be relied upon for a period not to exceed five years from the date of this notification.
❑ The property is located in one of the 20 Coastal Counties subject to regulation under the Coastal Area Management Act (CAMA).
You should contact the Division of Coastal Management in Morehead City, NC, at [phone] to determine their
requirements.
Placement of dredged or fill material within waters of the US, including wetlands, without a Department of the Army permit may
constitute a violation of Section 301 of the Clean Water Act (33 USC § 1311). Placement of dredged or fill material, construction or
placement of structures, or work within navigable waters of the United States without a Depat linent of the Army permit may
constitute a violation of Sections 9 and/or 10 of the Rivers and Harbors Act (33 USC § 401 and/or 403). If you have any questions
regarding this determination and/or the Corps regulatory program, please contact Ross Sullivan, Regulatory Specialist at 919-554-
4884 ext. 25 or roscoe.l.sullivan(a usace.army.mil.
C. Basis For Determination: See attached Approved Jurisdictional Determination Forms.
D. Remarks: The water bodies in the Project Area were flagged by Ross Sullivan and David E. Bailey
(USACE), and are shown within the p iect area on the attached sketch, labeled "Waters of the US
Sketch Map."
E. Attention USDA Program Participants
This delineation/determination has been conducted to identify the limits of Corps' Clean Water Act jurisdiction for the particular site
identified in this request. The delineation/determination may not be valid for the wetland conservation provisions of the Food Security
Act of 1985. If you or your tenant are USDA Program participants, or anticipate participation in USDA programs, you should request
a certified wetland determination from the local office of the Natural Resources Conservation Service, prior to starting work.
F. Appeals Information (This information applies only to approved jurisdictional determinations as indicated in B.
above)
This correspondence constitutes an approved jurisdictional determination for the above described site. If you object to this
determination, you may request an administrative appeal under Corps regulations at 33 CFR Part 331. Enclosed you will find a
Notification of Appeal Process (NAP) fact sheet and request for appeal (RFA) form. If you request to appeal this determination you
must submit a completed RFA form to the following address:
US Army Corps of Engineers
South Atlantic Division
Attn: Jason Steele, Review Officer
60 Forsyth Street SW, Room 10M15
Atlanta, Georgia 30303-8801

SAW-2017-01903
In order for an RFA to be accepted by the Corps, the Corps must determine that it is complete, that it meets the criteria for appeal
under 33 CFR part 331.5, and that it has been received by the Division Office within 60 days of the date of the NAP. Should you
decide to submit an RFA form, it must be received at the above address by 11/11/2017.
**It is not necessary to submit an RFA form to the Division Office if you do not object to the determination in this correspondence.**
Digitally signed by BAILEY Government,
o.E.13]9283]36
® cn=BAI16,o=U5.G.13792ent, ou=DOD, au=Pq, ou=D6A,
Corps Regulatory Official. Date:
Date: 201 J.09.1213:23:5 ]
Date of JD: 9/12/2017 Expiration Date of JD: 9/12/2022
The Wilmington District is committed to providing the highest level of support to the public. To help us ensure we
continue to do so, please complete the Customer Satisfaction Survey located at
http://corpsmapu.usace.army.mil/cm_apex/f?p=136:4:0
Copy furnished:
Stephanie Goss, NCDEQ-DWR, 3800 Barrett Drive, Raleigh, NC 27609

Project Area
Waters of the US Sketch Map
SAW-2017-01903
Pevehouse and Hodgins property
1010 and 1048 Crystal Forest Drive
Semora, Person County 09/11/2017

NOTIFICATION OF ADMINISTRATIVE APPEAL OPTIONS AND PROCESS AND
REQUEST FOR APPEAL
Applicant: Ewart and Marilynn Hodgins (PIN: 9070-01-46-0782.000) File Number: SAW-2017-01903 Date: 9/12/2017
Attached is:
See Section below
❑
INITIAL PROFFERED PERMIT (Standard Permit or Letter of permission)
A
❑
PROFFERED PERMIT (Standard Permit or Letter of permission)
B
❑
PERMIT DENIAL
C
/1
APPROVED JURISDICTIONAL DETERMINATION
D
❑
PRELIMINARY JURISDICTIONAL DETERMINATION
E
SECTION
Additional
or
I - The following identifies your rights and options regarding an administrative appeal of the above decision.
information may be found at or http://www.usace.army.mil/Missions/CivilWorks/RegulatoryProgramandPermits.aspx
the Corps regulations at 33 CFR Part 331.
A: INITIAL PROFFERED PERMIT: You may accept or object to the permit.
• ACCEPT: If you received a Standard Permit, you may sign the permit document and return it to the district engineer for final
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your
signature on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all
rights to appeal the permit, including its terms and conditions, and approved jurisdictional determinations associated with the
permit.
• OBJECT: If you object to the permit (Standard or LOP) because of certain terms and conditions therein, you may request
that the permit be modified accordingly. You must complete Section II of this form and return the form to the district
engineer. Your objections must be received by the district engineer within 60 days of the date of this notice, or you will
forfeit your right to appeal the permit in the future. Upon receipt of your letter, the district engineer will evaluate your
objections and may: (a) modify the permit to address all of your concerns, (b) modify the permit to address some of your
objections, or (c) not modify the permit having determined that the permit should be issued as previously written. After
evaluating your objections, the district engineer will send you a proffered permit for your reconsideration, as indicated in
Section B below.
B: PROFFERED PERMIT: You may accept or appeal the permit
• ACCEPT: If you received a Standard Permit, you may sign the permit document and return it to the district engineer for final
authorization. If you received a Letter of Permission (LOP), you may accept the LOP and your work is authorized. Your
signature on the Standard Permit or acceptance of the LOP means that you accept the permit in its entirety, and waive all
rights to appeal the permit, including its terms and conditions, and approved jurisdictional determinations associated with the
permit.
• APPEAL: If you choose to decline the proffered permit (Standard or LOP) because of certain terms and conditions therein,
you may appeal the declined permit under the Corps of Engineers Administrative Appeal Process by completing Section II of
this form and sending the form to the division engineer. This form must be received by the division engineer within 60 days
of the date of this notice.
C: PERMIT DENIAL: You may appeal the denial of a permit under the Corps of Engineers Administrative Appeal Process by
completing Section II of this form and sending the form to the division engineer. This form must be received by the division
engineer within 60 days of the date of this notice.
D:
information.
•
•
APPROVED JURISDICTIONAL DETERMINATION: You may accept or appeal the
ACCEPT: You do not need to notify the Corps to accept an approved JD. Failure to notify
date of this notice, means that you accept the approved JD in its entirety, and waive all
APPEAL: If you disagree with the approved JD, you may appeal the approved JD under
Administrative Appeal Process by completing Section II of this form and sending the form
must be received by the division engineer within 60 days of the date of this notice.
approved JD or provide new
the Corps within 60 days of the
rights to appeal the approved JD.
the Corps of Engineers
to the district engineer. This form
E: PRELIMINARY JURISDICTIONAL DETERMINATION: You do not need to respond to the Corps regarding the
preliminary JD. The Preliminary JD is not appealable. If you wish, you may request an approved JD (which may be appealed),
by contacting the Corps district for further instruction. Also you may provide new information for further consideration by the
Corps to reevaluate the JD.

, SECTION II - REQUEST FOR APPEAL or OBJECTIONS TO AN INITIAL PROFFERED PERMIT
REASONS FOR APPEAL OR OBJECTIONS: (Describe your reasons for appealing the decision or your objections to an initial
proffered permit in clear concise statements. You may attach additional information to this form to clarify where your reasons or
objections are addressed in the administrative record.)
ADDITIONAL INFORMATION: The appeal is limited to a review of the administrative record, the Corps memorandum for the
record of the appeal conference or meeting, and any supplemental information that the review officer has determined is needed to
clarify the administrative record. Neither the appellant nor the Corps may add new information or analyses to the record.
However, you may provide additional information to clarify the location of information that is already in the administrative
record.
POINT OF CONTACT FOR QUESTIONS OR INFORMATION:
If you have questions regarding this decision and/or the
appeal process you may contact:
District Engineer, Wilmington Regulatory Division
Attn: Ross Sullivan, Regulatory Specialist
Raleigh Regulatory Office
U.S Army Corps of Engineers
3331 Heirtage Tade Drive, Suite 105
Wake Forest, North Carolina 27587
919-554-4884 ext. 25
If you only have questions regarding the appeal process you may
also contact:
Mr. Jason Steele, Administrative Appeal Review Officer
CESAD-PDO
U.S. Army Corps of Engineers, South Atlantic Division
60 Forsyth Street, Room 10M15
Atlanta, Georgia 30303-8801
Phone: [phone]
RIGHT OF ENTRY: Your signature below grants the right of entry to Corps of Engineers personnel, and any government
consultants, to conduct investigations of the project site during the course of the appeal process. You will be provided a 15 day
notice of any site investigation, and will have the opportunity to participate in all site investigations.
Date:
Telephone number:
Signature of appellant or agent.
For appeals on Initial Proffered Permits send this form to:
District Engineer, Wilmington Regulatory Division, Attn: Ross Sullivan, Regulatory Specialist , 69 Darlington Avenue,
Wilmington, North Carolina 28403
For Permit denials, Proffered Permits and Approved Jurisdictional Determinations send this form to:
Division Engineer, Commander, U.S. Army Engineer Division, South Atlantic, Attn: Mr. Jason Steele, Administrative Appeal
Officer, CESAD-PDO, 60 Forsyth Street, Room 10M15, Atlanta, Georgia 30303-8801
Phone: [phone]

APPROVED JURISDICTIONAL DETERMINATION FORM
U.S. Army Corps of Engineers
This form should be completed by following the instructions provided in Section IV of the JD Form Instructional Guidebook.
SECTION I: BACKGROUND INFORMATION
A. REPORT COMPLETION DATE FOR APPROVED JURISDICTIONAL DETERMINATION (JD): 9/12/2017
B. DISTRICT OFFICE, FILE NAME, AND NUMBER: Wilmington District, Hyco Lake / Ewart Hodgins / Jerry Pevehouse / 1010 and
1048 Crystal Forest Drive / Semora / Person County, SAW-2017-01903
C. PROJECT LOCATION AND BACKGROUND INFORMATION: The project area for the Pevehouse/Hodgins approved
jurisdictional determination is situated south of Crystal Forest Drive on the following property parcel PINS: 9070-01-46-0782.000 and 9070-
01-36-9686.000. The project area is located near Roxboro, Person County, North Carolina. The Project Area is shown as the bold purple
boundary on the attached sketch labeled "Waters of the US Sketch Map."
State: NC County/parish/borough: Person City: Roxboro
Center coordinates of site (lat/long in degree decimal format): Lat. 36.514993 , Long. -79.087727
Universal Transverse Mercator: 17
Name of nearest waterbody: Hyco Lake
Name of nearest Traditional Navigable Water (TNW) into which the aquatic resource flows: Hyco River
Name of watershed or Hydrologic Unit Code (HUC): 03010104
• Check if map/diagram of review area and/or potential jurisdictional areas is/are available upon request.
❑ Check if other sites (e.g., offsite mitigation sites, disposal sites, etc...) are associated with this action and are recorded on a different
JD form:
D. REVIEW PERFORMED FOR SITE EVALUATION (CHECK ALL THAT APPLY):
❑ Office (Desk) Determination. Date:
® Field Determination. Date(s): 09/06/2017
SECTION II: SUMMARY OF FINDINGS
A. RHA SECTION 10 DETERMINATION OF JURISDICTION.
There are "navigable waters of the U.S." within Rivers and Harbors Act (RHA) jurisdiction (as defined by 33 CFR part 329) in the review
area. [Required]
❑ Waters subject to the ebb and flow of the tide.
❑ Waters are presently used, or have been used in the past, or may be susceptible for use to transport interstate or foreign commerce.
Explain:
B. CWA SECTION 404 DETERMINATION OF JURISDICTION.
There are "waters of the U.S." within Clean Water Act (CWA) jurisdiction (as defined by 33 CFR part 328) in the review area. [Required]
1. Waters of the U.S.
a. Indicate presence of waters of U.S. in review area (check all that apply): '
❑ TNWs, including territorial seas
® Wetlands adjacent to TNWs
® Relatively permanent waters2 (RPWs) that flow directly or indirectly into TNWs
❑ Non-RPWs that flow directly or indirectly into TNWs
❑ Wetlands directly abutting RPWs that flow directly or indirectly into TNWs
❑ Wetlands adjacent to but not directly abutting RPWs that flow directly or indirectly into TNWs
❑ Wetlands adjacent to non-RPWs that flow directly or indirectly into TNWs
® Impoundments of jurisdictional waters
❑ Isolated (interstate or intrastate) waters, including isolated wetlands
b. Identify (estimate) size of waters of the U.S. in the review area:
Non -wetland waters: 190 linear feet, 3 feet wide, and/or 0.3 acres.
Wetlands: 0.07 acres.
c. Limits (boundaries) of jurisdiction based on: 1987 Delineation Manual
Elevation of established OHWM (if known):
2. Non -regulated waters/wetlands (check if applicable):3
❑ Potentially jurisdictional waters and/or wetlands were assessed within the review area and determined to be not jurisdictional.
Explain:
SECTION III: CWA ANALYSIS
' Boxes checked below shall be supported by completing the appropriate sections in Section III below.
2 For purposes of this form, an RPW is defined as a tributary that is not a TNW and that typically flows year-round or has continuous flow at least "seasonally"
(e.g., typically 3 months).
3 Supporting documentation is presented in Section III.F.

A. TNWs AND WETLANDS ADJACENT TO TNWs
The agencies will assert jurisdiction over TNWs and wetlands adjacent to TNWs. If the aquatic resource is a TNW, complete
Section III.A.1 and Section III.D.1. only; if the aquatic resource is a wetland adjacent to a TNW, complete Sections III.A.1 and 2
and Section III.D.1.; otherwise, see Section III.B below.
1. TNW
Identify TNW: Hyco Lake
Summarize rationale supporting determination: Hyco Lake is a large impoundment of Hyco River and both Hyco Lake and
Hyco River routinely support navigation of motorized watercraft.
2. Wetland adjacent to TNW
Summarize rationale supporting conclusion that wetland is "adjacent": Wetlands WA and WB are both adjacent to Hyco Lake.
Both wetlands are located on the fringe of a finger of Hyco Lake near the confluence of an unnamed tributary to Hyco
Lake and Hyco Lake. No upland areas separated the wetlands from Hyco Lake.
B. CHARACTERISTICS OF TRIBUTARY (THAT IS NOT A TNW) AND ITS ADJACENT WETLANDS (IF ANY):
This section summarizes information regarding characteristics of the tributary and its adjacent wetlands, if any, and it helps
determine whether or not the standards for jurisdiction established under Rapanos have been met.
The agencies will assert jurisdiction over non -navigable tributaries of TNWs where the tributaries are "relatively permanent
waters" (RPWs), i.e. tributaries that typically flow year-round or have continuous flow at least seasonally (e.g., typically 3
months). A wetland that directly abuts an RPW is also jurisdictional. If the aquatic resource is not a TNW, but has year-round
(perennial) flow, skip to Section III.D.2. If the aquatic resource is a wetland directly abutting a tributary with perennial flow,
skip to Section III.D.4.
A wetland that is adjacent to but that does not directly abut an RPW requires a significant nexus evaluation. Corps districts and
EPA regions will include in the record any available information that documents the existence of a significant nexus between a
relatively permanent tributary that is not perennial (and its adjacent wetlands if any) and a traditional navigable water, even
though a significant nexus finding is not required as a matter of law.
If the waterbody4 is not an RPW, or a wetland directly abutting an RPW, a JD will require additional data to determine if the
waterbody has a significant nexus with a TNW. If the tributary has adjacent wetlands, the significant nexus evaluation must
consider the tributary in combination with all of its adjacent wetlands. This significant nexus evaluation that combines, for
analytical purposes, the tributary and all of its adjacent wetlands is used whether the review area identified in the JD request is
the tributary, or its adjacent wetlands, or both. If the JD covers a tributary with adjacent wetlands, complete Section III.B.1 for
the tributary, Section III.B.2 for any onsite wetlands, and Section III.B.3 for all wetlands adjacent to that tributary, both onsite
and offsite. The determination whether a significant nexus exists is determined in Section III.0 below.
1. Characteristics of non-TNWs that flow directly or indirectly into TNW
(i)
General Area Conditions:
Watershed size: 48 acres
Drainage area: 48 acres
Average annual rainfall: 46.6 inches
Average annual snowfall: 8.3 inches
(ii) Physical Characteristics:
(a) Relationship with TNW:
Tributary flows directly into TNW.
❑ Tributary flows through Pick List tributaries before entering TNW.
Project waters are
Project waters are
Project waters are
Project waters are
1 (or less)
1 (or less)
1 (or less)
1 (or less)
river miles from TNW.
river miles from RPW.
aerial (straight) miles from TNW.
aerial (straight) miles from RPW.
Project waters cross or serve as state boundaries. Explain:
Identify flow route to TNW5: The UT to Hyco Lake flows south through the project area and drains directly into
Hyco Lake.
° Note that the Instructional Guidebook contains additional information regarding swales, ditches, washes, and erosional features generally and in the arid
West.
5 Flow route can be described by identifying, e.g., tributary a, which flows through the review area, to flow into tributary b, which then flows into TNW.

Tributary stream order, if known: The UT to Hyco Lake appears to be a first order stream.
(b) General Tributary Characteristics (check all that apply):
Tributary is: ® Natural
❑ Artificial (man-made). Explain:
❑ Manipulated (man -altered). Explain:
Tributary properties with respect to top of bank (estimate):
Average width: 3-5 feet
Average depth: 3-4 feet
Average side slopes: 2:1.
Primary tributary substrate composition (check all that apply):
® Silts ❑ Sands
® Cobbles ❑ Gravel
® Bedrock ❑ Vegetation. Type/% cover:
❑ Other. Explain:
❑ Concrete
❑ Muck
Tributary condition/stability [e.g., highly eroding, sloughing banks]. Explain: Overall, the UT to Hyco Lake is stable
due to small watershed with intact forested riparian habitat. In addition, erosion is limited throughout much of
the channel due to exposed bedrock acting as grade control. There are several point locations within the channel
that are unstable and actively eroding.
Presence of run/riffle/pool complexes. Explain: The UT to Hyco Lake is predominately a run and riffles with few
pools due to relatively steep grades and exposed bedrock.
Tributary geometry: Relatively straight
Tributary gradient (approximate average slope): 10 %
(c) Flow:
Tributary provides for: Seasonal flow
Estimate average number of flow events in review area/year: 11-20
Describe flow regime: The flow regime in the UT to Hyco Lake are likely low to nonexistent throughout the
summer months, except during and after strong storm events when flows would be strong, with consistent
baseflow likely during the winter months.
Other information on duration and volume:
Surface flow is: Confined. Characteristics: Flow likely only in channel, with no evidence of overbank flow
Subsurface flow: Unknown. Explain findings:
❑ Dye (or other) test performed:
Tributary has (check all that apply):
® Bed and banks
OHWM6 (check all indicators that apply):
® clear, natural line impressed on the bank
® changes in the character of soil
❑ shelving
® vegetation matted down, bent, or absent
® leaf litter disturbed or washed away
❑ sediment deposition
❑ water staining
❑ other (list):
❑ Discontinuous OHWM.7 Explain:
❑ the presence of litter and debris
❑ destruction of terrestrial vegetation
® the presence of wrack line
® sediment sorting
® scour
❑ multiple observed or predicted flow events
❑ abrupt change in plant community
If factors other than the OHWM were used to determine lateral extent of CWA jurisdiction (check all that apply):
❑ High Tide Line indicated by: ❑ Mean High Water Mark indicated by:
❑ oil or scum line along shore objects
❑ fine shell or debris deposits (foreshore)
❑ physical markings/characteristics
❑ tidal gauges
❑ other (list):
(iii) Chemical Characteristics:
❑ survey to available datum;
❑ physical markings;
❑ vegetation lines/changes in vegetation types.
6A natural or man-made discontinuity in the OHWM does not necessarily sever jurisdiction (e.g., where the stream temporarily flows underground, or where
the OHWM has been removed by development or agricultural practices). Where there is a break in the OHWM that is unrelated to the waterbody's flow
regime (e.g., flow over a rock outcrop or through a culvert), the agencies will look for indicators of flow above and below the break.
7ibid.

Characterize tributary (e.g., water color is clear, discolored, oily film; water quality; general watershed characteristics, etc.).
Explain: The UT to Hyco Lake had little water at time of observation. Water was only present in the pools observed
within the channel. The water observed in the pools was mostly clear.
Identify specific pollutants, if known: Unknown
(iv) Biological Characteristics. Channel supports (check all that apply):
Riparian corridor. Characteristics (type, average width): The stream has a wide riparian corridor that is comprised of
a young forest dominated by pine trees.
❑ Wetland fringe. Characteristics:
® Habitat for:
D Federally Listed species. Explain findings:
❑ Fish/spawn areas. Explain findings:
❑ Other environmentally -sensitive species. Explain findings:
Aquatic/wildlife diversity. Explain findings: Seasonal water source for common urban-wildland interface wildlife
2. Characteristics of wetlands adjacent to non-TNW that flow directly or indirectly into TNW
(i)
Physical Characteristics:
(a) General Wetland Characteristics:
Properties:
Wetland size: acres
Wetland type. Explain:
Wetland quality. Explain:
Project wetlands cross or serve as state boundaries. Explain:
(b) General Flow Relationship with Non-TNW:
Flow is: Pick List. Explain:
Surface flow is: Pick List
Characteristics:
Subsurface flow: Pick List. Explain findings:
D Dye (or other) test performed:
(c) Wetland Adjacency Determination with Non-TNW:
❑ Directly abutting
❑ Not directly abutting
❑ Discrete wetland hydrologic connection. Explain:
❑ Ecological connection. Explain:
❑ Separated by berm/barrier. Explain:
(d) Proximity (Relationship) to TNW
Project wetlands are Pick List river miles from TNW.
Project waters are Pick List aerial (straight) miles from TNW.
Flow is from: Pick List.
Estimate approximate location of wetland as within the Pick List floodplain.
(ii) Chemical Characteristics:
Characterize wetland system (e.g., water color is clear, brown, oil film on surface; water quality; general watershed
characteristics; etc.). Explain:
Identify specific pollutants, if known:
(iii) Biological Characteristics. Wetland supports (check all that apply):
❑ Riparian buffer. Characteristics (type, average width):
❑ Vegetation type/percent cover. Explain:
❑ Habitat for:
❑ Federally Listed species. Explain findings:
❑ Fish/spawn areas. Explain findings:
❑ Other environmentally -sensitive species. Explain findings:
❑ Aquatic/wildlife diversity. Explain findings:
3. Characteristics of all wetlands adjacent to the tributary (if any)
All wetland(s) being considered in the cumulative analysis: Pick List
Approximately acres in total are being considered in the cumulative analysis.
For each wetland, specify the following:

Directly abuts? (Y/N) Size (in acres)
Directly abuts? (Y/N) Size (in acres)
Summarize overall biological, chemical and physical functions being performed:
C. SIGNIFICANT NEXUS DETERMINATION
A significant nexus analysis will assess the flow characteristics and functions of the tributary itself and the functions performed
by any wetlands adjacent to the tributary to determine if they significantly affect the chemical, physical, and biological integrity
of a TNW. For each of the following situations, a significant nexus exists if the tributary, in combination with all of its adjacent
wetlands, has more than a speculative or insubstantial effect on the chemical, physical and/or biological integrity of a TNW.
Considerations when evaluating significant nexus include, but are not limited to the volume, duration, and frequency of the flow
of water in the tributary and its proximity to a TNW, and the functions performed by the tributary and all its adjacent
wetlands. It is not appropriate to determine significant nexus based solely on any specific threshold of distance (e.g. between a
tributary and its adjacent wetland or between a tributary and the TNW). Similarly, the fact an adjacent wetland lies within or
outside of a floodplain is not solely determinative of significant nexus.
Draw connections between the features documented and the effects on the TNW, as identified in the Rapanos Guidance and
discussed in the Instructional Guidebook. Factors to consider include, for example:
• Does the tributary, in combination with its adjacent wetlands (if any), have the capacity to carry pollutants or flood waters to
TNWs, or to reduce the amount of pollutants or flood waters reaching a TNW?
• Does the tributary, in combination with its adjacent wetlands (if any), provide habitat and lifecycle support functions for fish and
other species, such as feeding, nesting, spawning, or rearing young for species that are present in the TNW?
• Does the tributary, in combination with its adjacent wetlands (if any), have the capacity to transfer nutrients and organic carbon that
support downstream foodwebs?
• Does the tributary, in combination with its adjacent wetlands (if any), have other relationships to the physical, chemical, or
biological integrity of the TNW?
Note: the above list of considerations is not inclusive and other functions observed or known to occur should be documented
below:
1. Significant nexus findings for non-RPW that has no adjacent wetlands and flows directly or indirectly into TNWs. Explain
findings of presence or absence of significant nexus below, based on the tributary itself, then go to Section III.D:
2. Significant nexus findings for non-RPW and its adjacent wetlands, where the non-RPW flows directly or indirectly into
TNWs. Explain findings of presence or absence of significant nexus below, based on the tributary in combination with all of its
adjacent wetlands, then go to Section III.D:
3. Significant nexus findings for wetlands adjacent to an RPW but that do not directly abut the RPW. Explain findings of
presence or absence of significant nexus below, based on the tributary in combination with all of its adjacent wetlands, then go to
Section III.D:
D. DETERMINATIONS OF JURISDICTIONAL FINDINGS. THE SUBJECT WATERS/WETLANDS ARE (CHECK ALL
THAT APPLY):
1. TNWs and Adjacent Wetlands. Check all that apply and provide size estimates in review area:
® TNWs: linear feet, wide, Or 0.3 acres.
® Wetlands adjacent to TNWs: 0.07 acres.
2. RPWs that flow directly or indirectly into TNWs.
❑ Tributaries of TNWs where tributaries typically flow year-round are jurisdictional. Provide data and rationale indicating that
tributary is perennial:
® Tributaries of TNW where tributaries have continuous flow "seasonally" (e.g., typically three months each year) are
jurisdictional. Data supporting this conclusion is provided at Section III.B. Provide rationale indicating that tributary flows
seasonally: The UT to Hyco Lake exhibited strong geomorphology with defined bed and bank, good substrate sorting,
and an OHWM as documented in Section B.1(ii)(c). Water was present in pools along the channel. Further, little to no
vegetation was present in the channel.
Provide estimates for jurisdictional waters in the review area (check all that apply):
® Tributary waters: 190 linear feet 3-5 wide.
❑ Other non -wetland waters: acres.
Identify type(s) of waters:

3. Non-RPWs8 that flow directly or indirectly into TNWs.
❑ Waterbody that is not a TNW or an RPW, but flows directly or indirectly into a TNW, and it has a significant nexus with a
TNW is jurisdictional. Data supporting this conclusion is provided at Section III.C.
Provide estimates for jurisdictional waters within the review area (check all that apply):
❑ Tributary waters: linear feet, wide.
❑ Other non -wetland waters: acres.
Identify type(s) of waters:
4. Wetlands directly abutting an RPW that flow directly or indirectly into TNWs.
❑ Wetlands directly abut RPW and thus are jurisdictional as adjacent wetlands.
❑ Wetlands directly abutting an RPW where tributaries typically flow year-round. Provide data and rationale indicating that
tributary is perennial in Section III.D.2, above. Provide rationale indicating that wetland is directly abutting an RPW:
❑ Wetlands directly abutting an RPW where tributaries typically flow "seasonally." Provide data indicating that tributary is
seasonal in Section III.B and rationale in Section III.D.2, above. Provide rationale indicating that wetland is directly
abutting an RPW:
Provide acreage estimates for jurisdictional wetlands in the review area: acres.
5. Wetlands adjacent to but not directly abutting an RPW that flow directly or indirectly into TNWs.
❑ Wetlands that do not directly abut an RPW, but when considered in combination with the tributary to which they are adjacent
and with similarly situated adjacent wetlands, have a significant nexus with a TNW are jurisidictional. Data supporting this
conclusion is provided at Section III.C.
Provide acreage estimates for jurisdictional wetlands in the review area: acres.
6. Wetlands adjacent to non-RPWs that flow directly or indirectly into TNWs.
❑ Wetlands adjacent to such waters, and have when considered in combination with the tributary to which they are adjacent and
with similarly situated adjacent wetlands, have a significant nexus with a TNW are jurisdictional. Data supporting this
conclusion is provided at Section III.C.
Provide estimates for jurisdictional wetlands in the review area: acres.
7. Impoundments of jurisdictional waters.'
As a general rule, the impoundment of a jurisdictional tributary remains jurisdictional.
❑ Demonstrate that impoundment was created from "waters of the U.S.," or
❑ Demonstrate that water meets the criteria for one of the categories presented above (1-6), or
❑ Demonstrate that water is isolated with a nexus to commerce (see E below).
E. ISOLATED [INTERSTATE OR INTRA-STATE] WATERS, INCLUDING ISOLATED WETLANDS, THE USE,
DEGRADATION OR DESTRUCTION OF WHICH COULD AFFECT INTERSTATE COMMERCE, INCLUDING ANY
SUCH WATERS (CHECK ALL THAT APPLY):10
❑ which are or could be used by interstate or foreign travelers for recreational or other purposes.
❑ from which fish or shellfish are or could be taken and sold in interstate or foreign commerce.
❑ which are or could be used for industrial purposes by industries in interstate commerce.
❑ Interstate isolated waters. Explain:
❑ Other factors. Explain:
Identify water body and summarize rationale supporting determination:
Provide estimates for jurisdictional waters in the review area (check all that apply):
❑ Tributary waters: linear feet, wide.
❑ Other non -wetland waters: acres.
Identify type(s) of waters:
❑ Wetlands: acres.
'See Footnote # 3.
9 To complete the analysis refer to the key in Section III.D.6 of the Instructional Guidebook.
1° Prior to asserting or declining CWA jurisdiction based solely on this category, Corps Districts will elevate the action to Corps and EPA HQ for
review consistent with the process described in the Corps/EPA Memorandum Regarding CWA Act Jurisdiction Following Rapanos.

F. NON -JURISDICTIONAL WATERS, INCLUDING WETLANDS (CHECK ALL THAT APPLY):
D If potential wetlands were assessed within the review area, these areas did not meet the criteria in the 1987 Corps of Engineers
Wetland Delineation Manual and/or appropriate Regional Supplements.
❑ Review area included isolated waters with no substantial nexus to interstate (or foreign) commerce.
❑ Prior to the Jan 2001 Supreme Court decision in "SWANCC," the review area would have been regulated based solely on the
"Migratory Bird Rule" (MBR).
❑ Waters do not meet the "Significant Nexus" standard, where such a finding is required for jurisdiction. Explain:
❑ Other: (explain, if not covered above):
Provide acreage estimates for non jurisdictional waters in the review area, where the sole potential basis of jurisdiction is the MBR
factors (i.e., presence of migratory birds, presence of endangered species, use of water for irrigated agriculture), using best professional
judgment (check all that apply):
❑ Non -wetland waters (i.e., rivers, streams): linear feet, wide.
❑ Lakes/ponds: acres.
❑ Other non -wetland waters: acres. List type of aquatic resource:
❑ Wetlands: acres.
Provide acreage estimates for non jurisdictional waters in the review area that do not meet the "Significant Nexus" standard, where such
a finding is required for jurisdiction (check all that apply):
❑ Non -wetland waters (i.e., rivers, streams): linear feet, wide.
❑ Lakes/ponds: acres.
❑ Other non -wetland waters: acres. List type of aquatic resource:
❑ Wetlands: acres.
SECTION IV: DATA SOURCES.
A. SUPPORTING DATA. Data reviewed for JD (check all that apply - checked items shall be included in case file and, where checked
and requested, appropriately reference sources below):
❑ Maps, plans, plots or plat submitted by or on behalf of the applicant/consultant: Aerial, Soils, and topo maps; "Waters of the US
Sketch Map"
® Data sheets prepared/submitted by or on behalf of the applicant/consultant.
® Office concurs with data sheets/delineation report.
❑ Office does not concur with data sheets/delineation report.
® Data sheets prepared by the Corps: Ross Sullivan and David E. Bailey (USACE) flagged wetlands in project area on 9/6/2017.
❑ Corps navigable waters' study:
❑ U.S. Geological Survey Hydrologic Atlas:
❑ USGS NHD data.
❑ USGS 8 and 12 digit HUC maps.
U.S. Geological Survey map(s). Cite scale & quad name: 1:24,000 Alton Quad
USDA Natural Resources Conservation Service Soil Survey. Citation: Person Co. Soil Survey
National wetlands inventory map(s). Cite name:
State/Local wetland inventory map(s):
FEMA/FIRM maps:
100-year Floodplain Elevation is: (National Geodectic Vertical Datum of 1929)
Photographs: ® Aerial (Name & Date): NC OneMap Statewide Orthoimagery (2013)
or ® Other (Name & Date): Photos provided by Ewart Hodgins on 8/13/2017
Previous determination(s). File no. and date of response letter:
Applicable/supporting case law:
Applicable/supporting scientific literature:
Other information (please specify): LiDAR (NC Floodmaps)
EOM ®❑❑❑❑®®
B. ADDITIONAL COMMENTS TO SUPPORT JD:

DocuSign Envelope ID: 247B3862-FC37-46A1-B180-DB5551407510
ROY COOPER.
Governor
JOHN NICHOLSON
Interim Secretory
S. DANIEL SMITH
Director
June 16, 2021
Ewart Hodgins
3629 West Mill Forest Court
Raleigh, NC 27606
(via email [e-mail])
NORTH CAROLINA
Environmental Quality
DWR # 202160637
Person County
Subject: APPROVAL OF 401 WATER QUALITY CERTIFICATION WITH ADDITIONAL CONDITIONS
Hodgins-1048 Crystal Forest Drive, Lot CC17, Semora
Dear Mr. Hodgins:
You have our approval for the impacts listed below for the purpose described in your application dated
May 21, 2021, received by the Division of Water Resources (Division) May 26, 2021 and payment
received June 7, 2021. These impacts are covered by the attached Water Quality General Certification
Number 4145 (GC4145). This certification is associated with the use of Regional Permit 198200030
(GP30) once it is issued to you by the U.S. Army Corps of Engineers. Please note that you should get any
other federal, state or local permits before proceeding with your project, including those required by
(but not limited to) Sediment and Erosion Control, Non -Discharge, and Water Supply Watershed
regulations.
The Division has determined that the proposed project will comply with water quality requirements
provided that you adhere to the conditions listed in the enclosed certification.
The following proposed impacts are hereby approved. No other impacts are approved, including
incidental impacts. [15A NCAC 02H .0506(b)]
Type of Impact
Amount Approved (units)
Permanent
Amount Approved (units)
Temporary
Open Water
Above Normal Pool
Rip Rap
480 (square feet)
1,500 (square feet)
Below Normal Pool
Rip Rap
240 (square feet)
960 (square feet)
This approval is for the purpose and design described in your application. The plans and specifications
for this project are incorporated by reference as part of this Certification. If you change your project,
you must notify the Division and you may be required to submit a new application package with the
NORD_E
�aearbnenl al Environmental 9ua1lly
North Carolina Department of Environmental Quality I Division of Water Resources
Raleigh Regional Office 13800 Barrett Drive I Raleigh, North Carolina 27609
919.791.4200

DocuSign Envelope ID: 247B3862-FC37-46A1-B180-DB5551407510
Hodgins-1048 Crystal Forest Drive, Semora
DWR# 20210637
401 Certification
Page 2 of 2
appropriate fee. If the property is sold, the new owner must be given a copy of this Certification and is
responsible for complying with all conditions. [15A NCAC 02H .0507(d)(2)].
If you are unable to comply with any of the conditions of the attached Water Quality General
Certification, you must notify the Raleigh Regional Office within 24 hours (or the next business day if a
weekend or holiday) from the time the permittee becomes aware of the circumstances.
The permittee shall report to the Raleigh Regional Office any noncompliance with, and/or any violation
of, stream or wetland standards [15A NCAC 02B .0200] including but not limited to sediment impacts to
streams or wetlands. Information shall be provided orally within 24 hours (or the next business day if a
weekend or holiday) from the time the permittee became aware of the non-compliance circumstances.
This approval and its conditions are final and binding unless contested. [G.S. 143-215.5]
This Certification can be contested as provided in Chapter 150B of the North Carolina General Statutes by
filing a Petition for a Contested Case Hearing (Petition) with the North Carolina Office of Administrative
Hearings (OAH) within sixty (60) calendar days. Requirements for filing a Petition are set forth in Chapter
150B of the North Carolina General Statutes and Title 26 of the North Carolina Administrative Code.
Additional information regarding requirements for filing a Petition and Petition forms may be accessed at
http://www.ncoah.com/ or by calling the OAH Clerk's Office at [phone].
One (1) copy of the Petition must also be served to the North Carolina Department of Environmental
Quality:
William F. Lane, General Counsel
Department of Environmental Quality
1601 Mail Service Center
Raleigh, NC 27699-1601
This letter completes the review of the Division under section 401 of the Clean Water Act and 15A NCAC
02H .0500. Please contact Stephanie Goss at 919-791-4256 or [e-mail] if you have
any questions or concerns.
Sincerely,
DocuSigned by:
St'U
BCDA9D825D4A46D...
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
Enclosures: GC 4145
cc: April Norton, USACE Raleigh Regulatory Field Office (via email)
DWR 401 & Buffer Permitting Unit electronic file

DWR Pre -Filing Meeting Request Form
NORTH CAROLINA
Envlronm¢ntcl avofiry
Contact Name *
Contact Email Address*
Project Owner*
Project Name*
Project County*
James A. Smithson
[e-mail]
James Smithson
Smithson shore rip rap
Person
Owner Address: * Street Address
1010 Crystal Forest Dr
Address Line 2
City State / Province / Region
Semora NC
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?
Stephanie Z Goss
Please give a brief project description below and include location information.*
Stabilize the shoreline next to an intermittent stream leading to Hyco
Lake. Adjacent land owner ( Ewart Hodgins) in August 2021
completed his project of rip raping his side of the stream. To ensure
shoreline stabilization on our side of the stream, we are requesting a
permit to rip rap our side of the stream. We are located in the Crystal
Cove Subdivision ,lot 18, tax map A-13 near Semora ,NC. Latitude
36.514993, Longitude -79.087727
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 *
c3Zowed tj'Y y 51rri,,Jes.r
Submittal Date 9/14/2021

Temporary impacts in square feet:
minimal
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:
330 to 440 sq. ft of rip rap
Temporary impacts (temporary clearing, construction corridor) in square feet:
Minimal
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): Small row of shrubs adjacent to
intermittent stream, and residential lawn behind shrubs.
11. Signat
wner/Agent's Signature' [15A NCAC 02H .0502(f)1 ate
`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.
P)'ev("7 S4. iPm/79-41 aee-i—elOt 004
715
FORM: SSGP 02-2017 Page 3 of 5

Water Resources
ENVIRONMENTAL QUALITY
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
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
Karen Higgins
DWR — 401 & Buffer Permitting Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
If sending via delivery service (UPS, FedEx, etc.)
Karen Higgins
DWR — 401 & Buffer Permitting Branch
512 N. Salisbury Street
Raleigh, NC 27604
A. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: James Smithson
Mailing Address: 1010 Crystal Forest Drive, Semora NC. 27343
Telephone Number: 217-620-6694 Fax Number:
E-mail Address: [e-mail]
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: Owner
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
Fax Number:
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. Attachment 1.
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. (Attachment 1) Photo 1 shows proposed area for
rip rap on left side of stream. Lake level was 18" to 24" below normal pool when photo was
taken. The nest box at left of photo is about 28"in height, and is on a 4 Ft pole for scale.
Photo 2 shows adjacent rip rap and the starting point of proposed riprap extending out 110 ft
to nest box shown in Photo 1.
4. Location of the property (where work is to be conducted)
County: Person Nearest Town: Semora
Lake/ river/ ocean adjacent to property: Hyco Lake
Property size (acres):2.26
Subdivision name or site address (include phase/lot number): Crystal Cove. Lot 18,Tax map A-
13
Directions to site - please include road names and numbers, landmarks, etc.: _See Driving
Directions( attachment 1.)
Latitude (in decimal degrees) 36° 30' 53" Longitude (decimal degrees) 79° 5' 16"
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Residential_
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Heavy rains cause intermittent stream to erode
streambank, causing excessive sedimentation in adjacent cove. Adjacent Landowner has
recently installed the permitted riprap on their side of the stream as shown in attachment 1
site photos. Work will involve clearing a small trench with a back hoe, laying an erosion control
fabric, and adding rip rap. Also attached (Attachment 1 is current COE approval for work on
this property (under previous owner Pevehouse) and recent approval for adjacent property rip
rap ( Hodgins)(Attachment 3).
7. Will work be conducted from land? Fl
From water? n
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:
330 to 440 sq. ft of rip rap
FORM: SSGP 02-2017 Page 2 of 5

Temporary impacts in square feet:
minimal
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:
330 to 440 sq. ft of rip rap
Temporary impacts (temporary clearing, construction corridor) in square feet:
Minimal
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): Small row of shrubs adjacent to
intermittent stream, and residential lawn behind shrubs.
11. Signature
James A Smithson signature attached
Owner/Agent's Signature* [15A NCAC 02H .0502(f)1 Date12/7/2021
*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.
FORM: SSGP 02-2017 Page 3 of 5

e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
Lake
(At Full Pond/ Normal Water Level)
Full Pond/ Normal Water Level
Shoreline
Plan View
Lake
(At Full Pond/ Normal Water Level)
Full Pond/ Normal Water Level
horerne --
2ft.x 150 ft.
additional clearing
* if necessary
Plan View
Existing Dock
30 ft x 7 ft
3ftx 150ft
Below full pond/ NWL
4ft x 150 ft
above full pond/ NWL
FORM: SSGP 02-2017 Page 4 of 5

La ke
(At Full Pond/ Normal Water Level)
fa
Tti
L
0
z
Side View
13,
C
0
CI-
U-
I
10ft. bank
height
Side Vi
3 ft. below full pond water level
4 ft. above full pond water level
2 ft. additional clearing
*if necessary
Existing bank
o
Q
1
AMPLE
FORM: SSGP 02-2017 Page 5 of 5