20220192 Ver 1_Shoreline Stabilization_20220201

Shoreline Stabilization Application Form
15A NCAC 02H.0500—Water Quality Certification,Shoreline Stabilization
FORM:SSGP 10-2013
DRAFT-NOT FOR USE AT THIS TIME
I. Applicant Information
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:* Kyle Buchanan
Email:* [e-mail]
Phone Number:* [phone]
(xxx)xxx-xxxx
Mailing Address:* Street Address
PO box 19
Address Line 2
City State/Province/Region
Bunn North Carolina
Postal/Zip Code Country
27508 US
Is there an agent working on the project?* * Yes
J No
Agent/Consultant Information
Name:* Gregory Poland
Company Affiliation:* Poland's Home Improvement
Email:* [e-mail]
Phone Number:* [phone]
(xxx)xxx-xxxx

Mailing Address:* Street Address
PO box 19
Address Line 2
City State/Province/Region
Bunn North Carolina
Postal/Zip Code Country
27508
A signed and dated copy of the Agent Authorization letter:*
110 Chuckwagon Dr agent authorization
2.23MB
letter.pdf
pdf only
Link to: Sample Agent Authorization Form

II. Project Information
Project Information[15A NCAC 02H .0502(a)&(b)]
Project Name:* 110 Chuckwagon Dr waterfront project
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
Property Address Lookup:* Street Address
110 Chuckwagon Drive
Address Line 2
City State/Province/Region
Louisburg NC
Postal/Zip Code Country
27549 US
Latitude:* 35.961414 Longitude:* -78.190038
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*
110 Chuckwagon Dr shoreline diagram
3.41 MB
2.pdf
110 Chuckwagon Dr plot plan_survey.pdf 2.86MB
110 Chuckwagon Dr shoreline
3.73MB
diagram.pdf
pdf only
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.)*
110 Chuckwagon Dr pic 4.pdf 5.62MB
110 Chuckwagon Dr pic 3.pdf 5.11MB
110 Chuckwagon Dr pic 2 water depth.pdf 4.72MB
110 Chuckwagon Dr picture 1.pdf 5.11MB
pdf only
4. Location of the property(where work is to be conducted)
Nearest Town:* Bunn
County:* Franklin

Lake/river/ocean adjacent to Lake Royale
property:*
Subdivisions name or site address:* 110 Chuckwagon Dr. Lake Royale
Include phase/lot number
Directions to site:*
Turn on Cheyenne Dr from Sledge rd. Enter gate. R on Shawnee
Dr, R on Sagamore Drive, L on Chuckwagon 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:*
Undeveloped residential
Residential,undeveloped,etc.
6. Property Size .469
Acres
7. Describe proposed work(include discussion as to how hardening of shoreline has been avoided,or
why it is necessary):
Shoreline is currently unaccessible virgin property. Property is on
main body of the lake and suffers a lot of wake. Rip rap in areas
and seawall where doc and boat house will be built to protect
shoreline and provide access. Most clearing will be within 20 ft of
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.)
400
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.)
1600
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)
Eight large trees to be removed within 50 ft buffer.Small saplings
and brush along shoreline to be removed as well to provide
accessibility.
Sketch: 110 Chuckwagon Dr plot plan_survey.pdf 2.86MB
pdf only

Sign and Submit
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
o $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
a 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
a I intend to electronically sign and submit the Shoreline Stabilization online form.
Full Name:* Gregory Alan Poland
Signature:*
Q110

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 Initial Review
Is this accepted into the review process?*
® Yes O No
Project 20220192
Number:*
Version:* 11
Select Reviewer:* Colleen Cohn:eads\cmcohn
Select Reviewing Office: Raleigh Regional Office-[phone]
Has payment been received?* Q No Payment Needed
O Fee Received
0 Need Fee-send electronic notification
What amount is owed?* QQ $240.00
0 $570.00
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Comments
i
Submit

EXAMPLE AGENT AUTHORIZATION FORM •
ertv Legal Description:
el ID: 023864
Jo. (if applicable) O5 Plan No.(if applicable)
et Address(if applicable): 1 l 0 CILhw&tiro ST
J)erty Owner
. J
iier Name(print): YAII e Y 2 `Yr ,1 C)---;;P.((,:{':n iA tjfq
perry owner's Address(if different than the above): 1004 Thorncroft Lane Apex,NC 27502
;ner Signature:
above registered property owners of the above property,do hereby authorize
U,Gs\/ll of c) 1 yv1f1`�IX4211._
sent Name Agent Company Name(if applicable) 1
act on my behalf and take all actions necessary for the application,processing,issuance and
:ceptance of this permit,certification or authorization including all standard and special conditions
:tached.
hereby certify that the above information submitted on this form and application is true and accurate
the best of my knowledge.
wthorized Agent Name!Company: OW/ AVAIL
wthorized Agent Signature:
late: January 26,2022

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