20221219 Ver 1_Shoreline Stabilization_20220908

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 9/6/2022
submitted on: *
Owner Information:
Name: * Lisa Willis
Email: * wildl [e-mail]
Phone Number: [phone]
(xxx)xxx-xxxx
Mailing Address:* Street Address
151 Lakeland Circle
Address Line 2
City
Mt Gilead
Postal / Zip Code
27306-9145
Is there an agent working on the project? * Yes
No
Agent/Consultant Information
State / Province / Region
NC
Country
US
Name: * Brittany Hepler
Company Affiliation: * Lake Life Permits, LLC.
Email: * [e-mail]

Phone Number:*
[phone]
(xxx)xxx-xxxx
Mailing Address:*
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:*
151 Lakeland Auth Agent.pdf 349.75KB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name: *
Willis 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: *
35.236999
Street Address
151 Lakeland Circle
Address Line 2
City State / Province / Region
Mt Gilead NC
Postal / Zip Code Country
27306-9145 US
Longitude: *-80.078330
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*
151 LAKELAND CR Survey.pdf 385.62KB
151 Lakeland Circle.pdf 515.26KB
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.)
Willis Pic 2.pdf 85.81KB
Willis Pic 1.pdf 122.1KB
Willis Pic 3.pdf 61.46KB
4. Location of the property (where work is to be conducted)
Nearest Town: * Mt. Gilead
County: * Montgomery
Lake/ river/ ocean adjacent to Lake Tillery
property:
Subdivisions name or site address:*
Emerald Shores/Lot # 9
Include phase/lot number
Directions to site: *
Head southwest on S Church St toward W Brooklyn Vlg Ave
Parts of this road may be closed at certain times or days
1 min (0.3 mi)
Take US-74 E and E Independence Blvd/E Independence Expy to Idlewild
Rd. Take exit 248 from E Independence Blvd/E Independence Expy
8 min (7.0 mi)
Continue on Idlewild Rd to NC-24 E/NC-27 E/Albemarle Rd
6 min (2.9 mi)
Follow NC-24 E/NC-27 E to NC-73 in Montgomery County
55 min (41.4 mi)
Take Lillys Bridge Rd and Emerald Shores Rd to Lakeland Cir
10 min (5.9 mi)
151 Lakeland Cir
Mt Gilead, NC 27306
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 and boathouse.
Residential, undeveloped, etc.
6. Property Size
0.82
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
Homeowner is requesting to add rip rap at the bottom of their concrete sea
wall to reinforce the stabilization as well as avoid any worsening erosion
and damage to sea wall. Approximate bank height 5'. Shorter in some
areas.
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.)
1080
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.)
540
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: Willis Pic 1.pdf 122.1KB
Willis Pic 2.pdf 85.81KB
Willis Pic 3.pdf 61.46KB
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:
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.
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:* Brittany Hepler
Signature:
Submittal Date: 9/6/2022

Initial Review
Is this accepted into the review process?* Yes No
Project Number:* 20221219 Version:* 1
Select Reviewer: * Chad Turlington:eads\ccturlington
Select Reviewing Office: Fayetteville Regional Office - [phone]
Has payment been received?* No Payment Needed
Fee Received
Need Fee - send electronic notification
What amount is owed?* $240.00
$570.00

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SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO.
PLAN NO. PARCEL ID: S
STREET ADDRESS: SI 14,e lid GIVrV
Alti-.6il6d lei 2'13
Please print: ,U In q WI I
Property Owner: V r
Property Owner:
The undersigned, registered property
owners of the above noted property, do hereby authorize
Itc
LI'I-L
(Contractor / Agen) (Name of consulting firm)
to aopermit
to my behalf and take all actions necessary for the processing, Issuance and acceptance of
p
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
Telephone:
We hereby certify the above information submitted in this application i5 true and accurate to the
best of our knowledge.
Authorized Signature
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etc.
• Location of any excavation or dredging below the Full Pond/ Normal Water
Level elevation
Full Pond/ Normal Water Le
Shoreline
Plan View
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Lake
(At Full Pond/ Norrnal Water Level)
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Side View
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