20140748 Ver 1_Shoreline Stabilization_20140721

State of North Carolina
DWRDepartment of Environment and Natural Resources
2 4 1 a� 7 4 J ision of Water Resources
Division of Water Resources 15A NCAC 02H .0500 — Water Certification, Shoreline Stabilization
FORM: SSGP 10 -2013
Shoreline Stabilization Application Form
Four copies of the application (including attachments) and the application fee should be sent to:
Division of Water Resources
401 & Buffer Permitting Unit
1650 Mail Service Center
Raleigh, NC 27699 -1650
I. Applicant Information [15A NCAC 02H .0502(a;)
1. Owner Informatior
Name:
Mailing Address:
Telephone Number: Ch J - / /��� "3�1�') Fax Number:
E -mail Address
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http: / /www.saw.usace. army. mi! / Portals /59 /docs /regulatory /regdocs /Permits /SAMP! E AGENT AUTH
ORIZAT!ON FORM.pdf) must be attached if the Agent has signed this application form.
Name: b
Company Affiliation:
Mailing Address: ,d D r; �, ZX
r? U
Telephone Number: "4L .1.a- ti 711- 6 Fax Number:
E -mail Address:
Person to receive the Certification Approval: .5 -e u e /,4L'4/�
II. Project Information [15A NCAC 02H .0502(a) & (b)]
1. Attach 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.
�. Provide a detailed site plan showing property boundaries and proposed locations of
vegetation clearing, structures (buildings, retaining walls, docks, impervious surfaces,
FORM: SSGP 10 -2013 Page 1 of 4

etc.), rip rap, excavation or dredging,below Full Pond / Normal Water Level,elevations,
and construction access corridors. You may use the diagram provided at the end of this
application form.
3. Attach a photograph of the shoreline/ buffer proposed to be stabilized. (include a scale
of some sort- a yardstick, shovel handle, etc.)
4. Location of the property (where work is to be conducted)
County: A "%zt, Nearest Town:
Subdivision name or site address (include phase /lot number): Z J ,,
Directions, to site - /please include road names and numbers, landmarks, etc...:: 1_1ZJ1&', r,�,;;f
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S. Describe t141. existing land use or condition of the site avthe�tlme of this application
(residential, undeveloped, etc.): _ �',, ,, ,, ; „R c� r jr/I
5. Property size (acres): a c
7. Lake/ river/ ocean adjacent to property: 1,��� . -G ;t • _!
8. Describe proposed work.(include discussion as to how, hardening of shoreline has'been -
avoided, or why it is necessary):o_�
4. Will work be conducted from land ?' From water? [�
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake level /, Normal Water Level in square feet or acres.
41-6
11. Total,amount of disturbance (including all,clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake, leve[/ 'Normal Water Level,and:50,feet land- ward,in
square feet or,acres:
12. 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):
r
Kner/Agent's Signature' [ f5A NCAC 02H .0502(f)l 'Date
'Agent's signature is valid only if an authorization letter from theowner is provided.
FORM: 55GP 10 -2013 Page,2 of 3,

US Post Office to 1549 Sagamore Dr, Louisburg, NC 27549 - Goog]... https://maps.google.com/niaps/ms?ie=UTF8&oe=LJTF8&msa=0 &ms
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Driving directions to 1549 Sagamore Dr, Louisburg, NC 27649
US Post Office
313 Main St
Bunn, NC 27508
[phone]
1. Head northeast on E Jewett Ave toward S Nash St
2. Continue onto Baptist Church Rd
3. Turn right onto Sledge Rd
4. Turn left onto Cheyenne Dr
S. Turn right to stay on Cheyenne Dr
6. Take the 1st left onto Shawnee Dr
7. Continue onto Pinto Dr
B. Turn right onto Tomahawk Dr
9. Turn left onto Lake Royale/Sagamore Dr
I of 2
Lake Royal 01
Properly Owner
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0.4 mi
0.1 mi
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0.3 mi
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To see all the details that are visible on the
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screen, use the "Print" link next to the map.
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Driving directions to 1549 Sagamore Dr, Louisburg, NC 27649
US Post Office
313 Main St
Bunn, NC 27508
[phone]
1. Head northeast on E Jewett Ave toward S Nash St
2. Continue onto Baptist Church Rd
3. Turn right onto Sledge Rd
4. Turn left onto Cheyenne Dr
S. Turn right to stay on Cheyenne Dr
6. Take the 1st left onto Shawnee Dr
7. Continue onto Pinto Dr
B. Turn right onto Tomahawk Dr
9. Turn left onto Lake Royale/Sagamore Dr
I of 2
Lake Royal 01
Properly Owner
1, 1
on
0 5ml
2.1 mi
0.4 mi
0.1 mi
262 ft
1 5 rrm
0.3 m
0.2 mi
0.3 mi
7/15/2014 9:05 AM

US Post,Office to 1549 Sagamore Dr,,Louisburg, NC 27549 - Googl.
10 Turn right,to stay on Lake, Royale /Sagamore Dr
Continue to follow Sagamore,Dr
11 Turn right onto Lake Royale/Sagamore Dr
12 Take the 1st right to stay on Lake,Royale /Sagamore Dr
13. Take the 1st right to stay on Lake Royale /Sagamore Dr
Destination will be on the right
1549 Saganore Dr
Lousbtug, NC 27549
https:Hmaps.google com/maps/ms?ie=UTF8&oe=UTF8&msa=O&ms..
0smi
220 ft
0 lm
0.4 mi
These directions are for planning purposes only You may find that construdtion, projects, traffic„ weaUiar, or other events may cause conditions to differ from the map results,
and you should ,plan your route accor`dmgty You must obey all signs or notices regarding your route
Map data ®2014 Google
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Please approximately sketch the,follo,wmg information on this plan (provide dimensions foreach
item, such as 10 ft x 100 ft) *.
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1. All proposed vegetation clearing -rio'
2 Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
3. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation r1 /A
4. Location of any proposed structures such as buildings, retaining walls, docks, etc
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of- construction access corridors /
FORM SSGP 10 -2013
Page 3 of 3

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State of North Carolina
DWR
JUL c� DQpaMttlent of environment and Natural Resources
Division of Water Resources
Division of Water Resources
T R QUALITY
D Np - wA
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tj�0500 —Water Quality Certification
Instructions for Application FORM SSGP 10 -2013
(Shoreline Stabilization 401 WQC to accompany USACE GP30, GP79, or GP80)
Instructions for Shoreline Stabilization Application
When to use this form —This application form should be used to apply for a 401 Water Quality
Certification to impact:
Description
U.S. Army Corps of
Engineers (USACE) Permit
Federal Energy Regulatory Commission (FERC) regulated lake
shore or bottom
GP30
Tennessee Valley Authority (TVA) regulated lake shore or bottom
GP30
Local government regulated lake shore or bottom
GP30
USACE Reservoir owned /regulated lake shore or bottom
GP79
Private lake shore or bottom
GP80 `.
When this form should not be used —This application form cannot used for wetland or
stream impacts. This information does not apply to landowners within the twenty coastal
counties that are affected by Division of Coastal Management (CAMA) rules.
For more information — If you have been advised that you require a 401 Water Quality
Certification, and would like more information about:
v The application process: http: / /porta1.ncdenr.org/ web /wq /swp /ws /401 /certsandpermits
How to download an application form:
http: / /Portal.ncdenr.org/ web /wq /swp /ws/ 401 /certsandpermits /apply /forms
r Application fees:
http: / /Porta1.ncdenr.org/ web /wq /swp /ws /401 /certsandPerm its /apply /fees
If you are unable to download this information or application, please call (919) 807 -6300 to
request an application with instructions.
Please note — Not all impacts require written authorization from DWR. This may include the
construction of docks or boathouses if there is no dredging or filling involved (other than the
pilings). For more information, please visit the following website:
http: / /portal.ncdenr.org/ web /wq /swp /ws/ 401 /certsandpermits /fags #always have to apply
How to apply — When submitting an application to DWR, please use the following instructions
as a checklist in order to ensure all required items are submitted. Adherence to these
instructions will help facilitate a quicker review time and reduce the amount of requested
additional information.
INSTRUCTIONS FOR APPLICATION SSGP307980 08 -13 & SUPPORTING DOCUMENTATION Page 1 of 3

j
Provide four (4) copies,of the application and supporting information (maps, drawings, etc.),
as well as the appropriate application fee '(see below), to'the Division of Water Resources,
401 & Buffer Permitting Unit, 1650 Mail Service Center, Raleigh, NC 27699 -1650.
Ap licant Information
[f Owner Information: Please provide complete and accurate contact information
❑' Agent Information: Per 15A NCAC 02H .0502 , an agent ,may be given signatory
authority for the owner /applicant if a signed and dated copy of an Agent Authorization
letter is included with the application. (A sample form may be found at
http: /Iwww.saw. usace.army. mil / Portals /59 /docs /regulatory /regdocs /Permits /_SAMPLE
AGENT AUTHORIZATION FORM.pdf)
Project Information
10;-,Vicinity/ Site Map: Some type of site map so that someone unfamiliar with the area can
locate your project. A county map or USGS topographic map indicating the project
location is usually sufficient.
® Site Plan: A site plan showing the location of the shoreline, location of the impacts to
the ,shoreline and /or lake bottom and the location and any vegetated areas that will be
impacted. In most cases the site plans do not have+to be professionally - prepared.
However, if you intend to conduct hydraulic dredging, professionally prepared drawings
will likely be, required for the spoil structures. See example below.
Photograph of shoreline to be impacted/ disturbed -
[3ZDescription of property and existing features on and near the site
©,Description of project and impacts / disturbance proposed
III. Signature
Per, 15A NCAC 02H .0502 ,, the application shall be considered a "valid application "' only
if it bears the signature of a responsible officer of the company, municipal official,
partner or owner. This signature certifies that the applicant has title to the property, has
been authorized by'the owner to apply for certification or is a public entity and has the
power of eminent domain.
IV. App ication Fee
The application must be accompanied by the appropriate application fee (checks made
out to the NC Division of Water'Resources). The application fee is as follows (pursuant
to G.S. 143- 215.3D):
➢ $240.00 for impacts to lake (below normal water level) of °less than 1 acre
➢ $570.00'for impacts to lake (below normal water level) of greater or equal to,1 acre
INSTRUCTIONS FOR APPLICATION SSGP307980 08 -13 & SUPPORTING DOCUMENTATION Page 2 of 3