20220693 Ver 1_Shoreline Stabilization_20220519

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 5/18/2022
submitted on: *
Owner Information:
Name: * William Gould
Email: * [e-mail]
Phone Number: [phone]
(xxx)xxx-xxxx
Mailing Address:* Street Address
24464A River Loop Drive
Address Line 2
City
Albemarle
Postal / Zip Code
28001
State / Province / Region
NC
Country
US
Is there an agent working on the project?* Yes
No
Agent/Consultant Information
Name: * Brittany Hepler
Company Affiliation: * Lake Life Permits
Email:* [e-mail]

Phone Number:*
Mailing Address:*
[phone]
(xxx)xxx-xxxx
Street Address
123 Institute St
Address Line 2
Unit 393
City State / Province / Region
Mooresville NC
Postal / Zip Code Country
28115 US
A signed and dated copy of the Agent Authorization letter:*
Gould Sample Agent.pdf 362.12KB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name: *
Gould Stabilization
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:*
35.315536
Street Address
24464A River Loop Drive
Address Line 2
City State / Province / Region
Albemarle NC
Postal / Zip Code Country
28001 US
Longitude: *-80.083897
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*
Survey Breakdown of Walls.pdf 538.84KB
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.)
GOULD PIC 1 PDF.pdf 75.6KB
Gould Pic 2 PDF.pdf 193.13KB
4. Location of the property (where work is to be conducted)

Nearest Town: * Albemarle
County:* Stanly
Lake/ river/ ocean adjacent to Tillery
property:
Subdivisions name or site address:*
Directions to site: *
Lot 12 and 1 and a portion of lot 14
Include phase/lot number
Head southwest on S Church St toward W Stonewall St
1 min (0.3 mi)
Take NC-27 E to River Haven Dr in Stanly County
1 hr 5 min (48.5 mi)
Continue on River Haven Dr. Drive to River Loop Dr
2 min (0.6 mi)
Turn left onto River Haven Dr
0.4 mi
Slight right onto River Loop Dr
Destination will be on the right
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 Home, 3 separate structures
Residential, undeveloped, etc.
6. Property Size
0.57
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
Installing 90' of rip rap in front of wooden sea wall to reinforce the
structure and to avoid further erosion. Tearing out 105' of wooden sea wall
and replacing with boulders. Reinforcing 145' of concrete wall with
railroad valises. Installing boulders behind this wall.
8. How will the work be done?*
Lv 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.)
915
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.)
610
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)
none

Sketch: GOULD PIC 1 PDF.pdf
Gould Pic 2 PDF.pdf
Application Fee:
75.6KB
193.13KB
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:
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
• 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.
a 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");
• 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");
a 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:* Brittany Hepler
Signature:
Submittal Date: 5/18/2022

Initial Review
Is this accepted into the review process?* Yes No
Project Number:* 20220693 Version:* 1
Select Reviewer: * Doug Perez:eads\djperez
Select Reviewing Office: Mooresville 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 DESCCR(1P1TTIIOrN , `
LOT NO,YpIZ,I r P W
r LAN NO. PARCEL ID: 7-1-1,0111.PI(e 'lu
STREET ADDRESS: 7U1(at- over- Loop Pt`
f1�?Pa vlart� N L 28vo I
Please rint: " A11 /UutPropaOwner. 1. I�
Property Owner:
The undersigned,�� igd,registered1' property owners of the above noted property,
do hereby authorize
f
1/ k" I IlM Y 1-1'l,t"Pir ,of I 4C I-i e To �'ttc ,'"-"
(Contractor/Agent) (Name of consulting firm)
to act on mybehalf and take all actions necessaryforthe processing,issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address(if different than property above):
E2 3 I vlS-+E(h'tte Sf►'ec-l- 1M4I ?i-f3 YVloevm¢ l l�
Telephone: /54 Z•*o 1 774 `z.' 31 K
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
k___9(
t zed Signature Authorized Signature
Date: tIt it Date:
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