HomeMy WebLinkAbout20220915 Ver 1_Shoreline Stabilization_20220708Shoreline 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 *
jeffreywebb2006@yahoo.com
Please provide an email address for payment and requests for more information here.
Pre -Filing Meeting Date Request was 7/6/2022
submitted on: *
Owner Information:
Name: *
Email: *
Phone Number:
Mailing Address: *
Richard C Polk
jeffreywebb2006@yahoo.com
(910)571-7010
(xxx)xxx-xxxx
Street Address
10900 Pioneer Mill RD
Address Line 2
City
Concord
Postal / Zip Code
28025
State / Province / Region
NC
Country
US
Is there an agent working on the project?* Yes
No
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name: * Polk Property shoreline
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:*
35.296200
Street Address
114 Barons Ct
Address Line 2
City State / Province / Region
Mt Gilead NC
Postal / Zip Code Country
27306 US
Longitude: *-80.085740
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*
shoreline sketch.pdf 169.82KB
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.)
shoreline picture.pdf 95.08KB
4. Location of the property (where work is to be conducted)
Nearest Town: * Mt. Gilead NC
County: * Montgomery
Lake/ river/ ocean adjacent to Lake Tillery
property:
Subdivisions name or site address:*
114 Barons CT Tillery Tradition
Include phase/lot number
Directions to site: *
Hwy 73 to Lillys Bridge RD
RT on Tradition DR
RT on Shagbark
Lt on Barons CT
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, undeveloped
Residential, undeveloped, etc.
6. Property Size
1.69
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
Shoreline stabilization
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.)
450sf
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.)
9000sf
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)
several pine trees and undergrowth
Sketch:
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
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.
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
o I intend to electronically sign and submit the Shoreline Stabilization online form.
Full Name:*
Signature:
Richard Chadwick Polk
Submittal Date: 7/6/2022
Initial Review
Is this accepted into the review process?* Yes No
Project Number:* 20220915 Version:* 1
Select Reviewer: * Chad Turlington:eads\ccturlington
Select Reviewing Office: Fayetteville Regional Office - (910) 433-3300
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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