20220756 Ver 1_Shoreline Stabilization_20220601

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 4/26/2022
submitted on: *
Owner Information:
Name: *
Email: *
Phone Number:
Mailing Address: *
Ojenik Kakade
[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
United States
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 United States
A signed and dated copy of the Agent Authorization letter:*
107 Chuckwagon agent authorization .pdf 306.44KB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name: *
107 Chuckwagon Dr 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: *
Latitude:*
35.962365
Street Address
107 Chuckwagon Drive
Address Line 2
City State / Province / Region
Louisburg NC
Postal / Zip Code Country
27549 US
Longitude: *-78.189265
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*
107 Chuckwagon Dr survey.pdf 4.19MB
107 Chuckwagon Dr shoreline detail.pdf 4.68MB
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.)
107 Chuckwagon Dr pic4.pdf 8.67MB
107 Chuckwagon Dr pic3.pdf 8.23MB
107 Chuckwagon Dr pic2.pdf 8.46MB
107 Chuckwagon Dr picl.pdf 7.39MB
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: *
Lake Royale lot #2039
Include phase/lot number
Directions to site: *
Turn on to Cheyenne Drive from Sledge road. Go through gate and go
right on Shawnee, right on Sagamore, left on Chuck wagon.
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, undeveloped, etc.
6. Property Size .46
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
Build new vinyl seawall along entire shoreline, around proposed boat slip
area and cut back into land approximately 5 ft along each property line.
This property is completely undeveloped and this project is to stabilize the
shoreline and provide clean access to waterfront.
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.)
3000
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)
Only two trees need to be removed and they are marked clearly on the
shoreline diagram. Also small brush and weeds to be cleared within buffer
area. The two trees that need to be removed are in buffer 1.

Sketch: 107 Chuckwagon Dr shoreline detail.pdf 4.68MB
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
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.
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");
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");
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
o I intend to electronically sign and submit the Shoreline Stabilization online form.
Full Name:*
Signature:
Submittal Date:
Gregory Alan Poland
6/1/2022

Initial Review
Is this accepted into the review process?* Yes No
Project Number:* 20220756 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

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