20220570 Ver 1_Shoreline Stabilization_20220418

Shoreline Stabilization Application Form
NORTH CAROLINA
Environmental Quality
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 *
[e-mail]
Please provide an email address for payment and requests for more information here.
Pre -Filing Meeting Date Request was 11/30/2021
submitted on: *
Owner Information:
Name: *
Email: *
Phone Number:
Mailing Address: *
Dilip Kothamasu
[e-mail]
[phone]
(xxx)xxx-xxxx
Street Address
PO box 19
Address Line 2
City
Bunn
Postal / Zip Code
27508
State / Province / Region
North Carolina
Country
US
Is there an agent working on the project?* Yes
No
Agent/Consultant Information
Name:* Gregory Poland
Company Affiliation: * Poland's Home Improvement
Email: * [e-mail]

Phone Number:*
Mailing Address:*
[phone]
(xxx)xxx-xxxx
Street Address
PO box 19
Address Line 2
City State / Province / Region
Bunn North Carolina
Postal / Zip Code Country
27508 US
A signed and dated copy of the Agent Authorization letter:*
Dilip agent authorization form .pdf 3. 16MB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name: *
1069 Sagamore Dr
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: *
Latitude:*
35.961660
Street Address
1069 Sagamore Drive
Address Line 2
City State / Province / Region
Louisburg NC
Postal / Zip Code Country
27596-9607 US
Longitude: *-78.187390
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*
1069 Sagamore plotl.pdf
1069 Sagamore plotl.pdf
Please use the diagram at the link below:
4.42MB
4.37MB
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.)
1069 Sagamore pic3.pdf 8.67MB
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: *
1069 Sagamore Dr Lake Royale
Include phase/lot number
Directions to site: *
Turn on Sledge road from nc98 right on Cheyenne Drive into Lake Royale
subdivision right on Shawnee Drive Right on Sagamore Drive.
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 waterfront property.
Residential, undeveloped, etc.
6. Property Size .561
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
Build vinyl seawall around entire shoreline. Excavate boat slip for
proposed 12x24 boathouse. For recreational and cosmetic purposes. Clear
six small trees from buffer 1 (1st 20' from shoreline). Boat slip to be
excavated 16 ft back and 16 ft wide; 32-in deep.
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.)
300
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.)
1400
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)
6 Medium sized trees removed within first 20 ft from shoreline.
Sketch: 1069 Sagamore plot2.pdf 4.37MB
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):
a $240.00 for impacts to lake (below normal water level) of less than 1 acre
a $570.00 for impacts to lake (below normal water level) of greater or equal to 1 acre
By digitally signing below, I certify that:
a 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");
a 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");
• I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
• I intend to electronically sign and submit the Shoreline Stabilization online form.
Full Name:* Gregory Alan Poland
Signature:
Submittal Date: 4/12/2022

Initial Review
Is this accepted into the review process?* Yes No
Project Number:* 20220570 Version:* 1
Select Reviewer: * Colleen Cohn:eads\cmcohn
Select Reviewing Office: Raleigh Regional Office - [phone]
Has payment been received?* ( No Payment Needed
C Fee Received
C• Need Fee - send electronic notification
What amount is owed?*
C• $240.00
C $570.00

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID: 1�� V `
STREET ADDRESS: 1 fl;
Please print:
Property Owner: oCrroa
0 17)
Property Owner: tcYi2st`1L 1
The undersigned, registered property owners of the above noted property, do hereby authorize
(Contract, r / Agent)
, of PC a ylci S HGrI e rnprCV rn'
(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 (f different than property above)
Telephone: b - 30 al 3L1O
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Sjnature
Date: 0 3 / 15 /7-o
Au horizzed Signatur
Date: 03///..5?_,P?6,1-,

R ENCES: Lot 2024, Lake Royale Subdivision
Deed Book 1725. Page 426
Deed Pool, 1824, Page 15
Deed Book 2184. Pegs 1441 - Restrictive Covenants
Map Book 12. Page 59
Tax Record No. 020049
LEGEND;
•
0
found iron as noted
found Mog nail as noted
set iron as noted
property tine plotted from record
easement or buffer line
100-Year Flood Limits line
MOTE Area of Lot = 0.561 Acre ( Coordinate Method )
NOTE- N.C. Grid station unovailabde within 2000' at this time.
NOTE: This survey is subject to alp. easements, agreements.
rights-ot-way and restrictive covenants recorded prior to
the dote of this survey.
NOTE: 100-Year Flood Limits fine plotted from FEMA DRRM
Franklin County, MC", Mop No. 3720284000L, effective
04/16/13 (https://flood.nc-gov/ncfloodf)
1, Wl'arw T. Dement, dr., certify that this plat was drawn under my supervision from on
actual Feld survey mode under eery supervision (deed descript'wn recorded in Book 1726,
Pope 426 !r Book 1824, Pogo 15; that the boundaries not surveyed ore clearly ind:koted as
drown from mlorrnotion found in Idop Book 12. Page 59. that the ratio of precision erg cal—
ytoted io 1/10.000: that this survey is of on existing parcel or parcels of rood and does not
creole a new street or change an existing street; that this nap ,has prepared in occordonee
w/BS 47-30 es omended. witness my original signature, license n mbar end 1e01, this 1st
of July. 2021,
Course
Radius
595.31'
595.31'
Length
5 03'30'05' E
100-Year Flood Limits
Professional Land Surveyor
Distance
15.49'
S 00' 54'00" E
S 05'15'15" W
( See Notes ) /
Now a Formerly rr y
Lake Royale raana 1/2`
P.O.A.. Inc. Rai. ./2 2-
- ( D.5, 1803, P. 923 ) i 1 i/ wo.. Deana
--LAKE— 4 I t
Pone Sir Wee
Reba %To.
Moot Grwe4 33`
to Mr e'Loco \
sot Ree/TTo? 1'
s.w.0,d +U
To L200 er Dave
LAKE —
Nor. or Formerly
Lake Royale
P.O.A., Inc.
( B.B. 1803, P- 923 )
( 2025 )
Now or Formerly
Richard B. Wainwright,
( 0.9. 1140, P. 974 )
r-_
/.6-
1,; ;0/
b'A
Fewq 1/2' Iran
z R.'Crew Utility
Abair. Crewe
1 0'
'�— 5 85'47'25'E otalasarrr9
�346.95'5'
282.24 t
2026 1
364,
a, ` N
85'42 5iTotoi=
35 1.36'�- iRwff 10Utlity Easement
New Wound
50' Tar River Basin
Riparian Buffer
( 2023 )
Now or Formerly
Daniel R. Freitas, et ux
( 6.8. 1052, P. 962 )
PLAT OF BOUNDARY SURVEY FOR
DILIP KOTHAMASU
VICINITY MAP_
( No Scale
Ft,na 1/2' eon.
Rrdv w/Tap 2"
renew afoum
Found I/7'Reber *Ai* va:
mow 6eeed
Found T/2' Imn
Reba *trap 1'
Nam a,aw,d
(Property Owner - Michael Bailey, et ux)
1069 Sagamore Drive. Cypress Creek Township, Franklin County, NC
Date: July 1, 2021
60 120 180
GRAPHIC SCALE - FEET
Surveyed & Mopped By
WILLIAM T. DEMENT, JR., Professional Land Surveyor, PA
L-1456, C-0649
.9.74l15-6t59 (M)919-496-9502
Street Louisburg, N.C.
LAKE
ROYALE
roved 1/2' Iron
Reber .iTee
flush iv/Grouse
NOTE. (owner'' name shown for i irivoon9
purposes only and data not conatit.to
title cerli#ication.
27549 (File No. 3953-2)

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