20221311 Ver 1_Riparian Buffer Authorization_20220922

Buffer Authorization Application Form
15A NCAC 02B .0233 (8)(b), .0243 (8)(b), .0250 (11)(b), .0259 (8)(b), .0267 (11)(c), .0607 (e)(2) Buffer Authorization Online Form -
Update 10/23/2018
Water RENVIRONMENTAL QUA
LITY
JIM
A. Owner/Applicant Information
For instructions on how to fill out this form, see the Buffer Authorization Application Help Document posted on DWR's 401 & Buffer page.
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.
A. Owner/Applicant Information
General Information
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Primary Contact Email:* [e-mail]
Please list the contact person's email for questions or payment on this project if needed.
Is this project a public transportation project?* 0 Yes
O No
Who is submitting the application?*
O Owner
O✓ Applicant other than Owner
O Agent
Check all that apply
Is there an agent working on this application but 0 Yes
not submitting it?* ( No
1. Property Owner Information:
....................................................
la. Name on Recorded Deed:*
1b. Responsible Party:
lc. Mailing Address:*
Tillery Land LLC
David Cuthbertsosn
(for Corporations)
Street Address
2627 Brekonridge Centre Drive
Address Line 2
City State / Province / Region
Monroe NC
Postal / Zip Code Country
28110-5629 US
le. Email Address: * jkikershadyoakhomes@gmail.c
1d. Telephone:* 17046226644 om
2. Applicant's Information (if different from owner):
2a. Name:* Jeff Kiker
2b. Company Affiliation: Shady Oak Homes Ilc

2c. Mailing Address:*
Street Address
525 baucom deese rd
Address Line 2
City State / Province / Region
Monroe North Carolina
Postal / Zip Code Country
28110 united states
2d. Telephone:* 17046226644
2e. Email Address: *
[e-mail]
If the applicant is not the property owner, in addition to providing the Agent's information, select `Applicant other than Owner' above, enter the applicant's
information, and attach an authorization granting the applicant owner approval.

B. Project Information and Prior Project History
B. Project Information and Prior Project History
1. Project Information
la. Name of Project:* 20 Emerald Shores
(Subdivision, facility, or establishment name)
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.
1b. Is this a publicly -funded transportation project?*
Yes
Le) No
Id. Subdivision Name: Emerald Shores
le. Nearest Municipality: Mt. Gilead
If. Property Size: 0.50
acres
1g. County (or Counties) where the project is located:*
Montgomery
1h. Property ID#
6574-14-44-2765
Tax PIN or Parcel id
1i. Deed Information
Date of Purchase
6/19/2017
Type of Book
Book#
Page#
Deed
791
1
Map
1j. Attach a copy of the recorded map that indicates when the lot was last platted.
Click the upload button or drag and drop files here to attach document
Lake Tillery_Lot 20_Emerald Shores Road.pdf 847.28KB
PDF only
1 k. How would you like to provide the Latitude and Longitude information?*
Address Lookup
0 Manually
Address Lookup
Street Address
1307 Emerald Shores Road
Address Line 2
City State / Province / Region
Mt Gilead NC
Postal / Zip Code Country
28110 United States

Latitude* 35.2419277 Longitude* -80.0908553
11. Is the project located in any of North Carolina's twenty coastal counties?*
O Yes
O No
Coastal Management information can be found at:
o About Coastal Management
o Staff Listing
o Coastal County Lookup
2. Surface Waters
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
2a. Name of the nearest body of water to proposed project: *
Lake Tillery
Link to Soil Surveys for North Carolina Counties. (Please see instructions in the Help Document to determine the most recent published version.)
2b. Water Quality Classification of nearest receiving water: *
Montgomery
2c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: *
0
(linear feet only)
3. Project Description:
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this application:
New Construction
3b. Attach an 8 1/2 x 11 excerpt from the most recent version of the USGS topographic map indicating the location of the site.
Click the upload button or drag and drop files here to attach document
topo map.pdf 587.78KB
PDF only
Link to TOPO Map lookup: https://viewer.nationalmap.gov/basic/
3c. Attach an 8 1/2 x 11 excerpt from the most recent version of the published County NRCS Soil Survey Map depicting the project site.
Click the upload button or drag and drop files here to attach document
soil type map.pdf
PDF only
926.15KB
Link to Soil Surveys for North Carolina Counties. (Please see instructions in the Help Document to determine the most recent published version.)
4. Proposed Activity
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Provide a detailed description of the proposed activity including its purpose and include the type of equipment to be used:*
Attach a site plan as applicable to the project:
Click the upload button or drag and drop files here to attach document
PDF only
** Below is a link with instructions on what you will need to show on your site plan.
http://edocs.deq.nc.gov/VVaterResources/O/doc/402224/Page1.aspx
5. Jurisdictional Determinations

5a. Have jurisdictional wetlands or stream determinations by the Corps or State been requested or obtained for this property/project
(including all prior phases) in the past?*
Yes
v No
6. Project History
6a. Have permits or certifications been requested or obtained for this project (including all prior phases) in the past?*
Yes
O No
7. Future Project Plans 0 .........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
7a. Is this project a phased project?*
O Yes
O No

C. Proposed Impacts Inventory
C. Proposed Impacts Inventory
Buffer Impacts
la. Project is in which protected Basin?*
Neuse River Basin (15A NCAC 026.0233)
O Catawba River Basin (15A NCAC 026.0243)
O Randleman Lake Watershed (15A NCAC 026.0250)
O Tar -Pamlico River Basin (15A NCAC 026.0259)
O Jordan Lake Watershed (15A NCAC 026.0267)
O Goose Creek Watershed (15A NCAC 026.0606 & 15A NCAC 026.0607)
You can find which river basin you live in at the link below.
http://www.eenorthcarolina.org/riverbasins-gis-map.asp
1c. Individually list all buffer impacts below. If any impacts require mitigation, then you MUST fill out Section D of this form.
Please note: if the impact you list below requires mitigation choose "allow w/mitigation" under impact type.
Site# - Reason
Stream Name
Buffer Impact*
Impact Type*
Zone 1
Zone 2
Map label (e.g. Road
Crossing 1)
Perm or Temp
0.00
Square
Feet
0.00
Square
Feet
Total Zone 1 Impacts: 0.00
Total Zone 2 Impacts: 0.00
Total Buffer Impacts: 0.00
Comments:

D. Impact Justification and Mitigation
D. Impact Justification and Mitigation
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
1. Avoidance and Minimization
la. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project.*
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.*

E. Diffuse Flow Plan
E. Diffuse Flow Plan
All buffer impacts & high ground impacts require diffuse flow or other form of stormwater treatment. If the project is subject to a state implemented
riparian buffer program, upload a plan that fully documents how diffuse flow will be maintained. All stormwater control measures (SCMs) must be
designed in accordance with the NC Stormwater Design Manual. Associated supplement forms and other documentation must be provided.
For a list of options to meet the diffuse flow requirements, click here.
la. What type of SCM are you providing?*
U Level Spreader
O Vegetated Conveyance (lower SHWT)
O Wetland Swale (higher SHWT)
u Proposed project will not create concentrated stormwater flow through the buffer
u Other SCM that removed minimum of 30% nitrogen
lc. Diffuse Flow Documentation*
Click the upload button or drag and drop files here to attach document
PDF only

F. Supplementary Information
F. Supplementary Information
Environmental Documentation
la. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?
O Yes
CV No
Violations
2a. Is the site in violation of DWR Wetland Rules (15A NCAC 02H .0500), Isolated Wetland Rules (15A NCAC 02H .1300), DWR Surface
Water or Wetland Standards, or Riparian Buffer Rules (15A NCAC 02B .0200)?
O Yes
O No
2b. Is this an after -the -fact buffer authorization application?
O Yes
® No
G. Additional Information
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Please upload any additional information you would like the Division to consider during application review.
Additional Attachments: Click the upload button or drag and drop files here to attach document
PDF only
Additional Comments:

G. Sign and Submit
G. Sign and Submitt
By digitally signing below, I certify that:
o I have given true, accurate, and complete information on this form;
o I agree that submission of this 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 application form."
Print Name: * jeff kiker
Signature*
Submission Date:
09222022
(Auto populated field)

• • Y 1 , s't is out:4NC'
HAMMER
JERRY
COLL
� INS T
ERREN S &C
CE USA
LLC
..
• L,
i
B
TIL
LER
Y L W
ADD HI
LLCtr,
EY OU
`RI RY KC
M UR
v

HAMMER
JERRYI7
INS T .
ERREN •yS&C
j,
CE % USA
LLC
•
.
TIL
LER
YLW
•
.
.
A1ID HI
LLC TL K
EY OU
RI RY KO
M UR
AR i'Av
mp
RK
.
■
■

l• • . wawa Au.dart-s--... 4. i ( 1N. re' . 11-^o 'Ararat

1. 1EPFSEY L GREEN, CERTIFY TIFAT TIES PUT WAS DRAWN DIETER
MY SUPERVISION FROM 1N ACSDIL SURYIY MADE FD' 105 TEAT TEE
BOUNDARIES NOT SURVEYED NEE CLEARLY INDICATED AS DRAWN FROM
INFORMATION AS SHOWN: THAT TEE RATIO OP PRECISION AS C1[L'OUSED IS
1:7600. TEAT EMS PUT WAS PtBP*RE0 w ICCOROINCE SITE G.S. 47-50.
1S VENDED. ERNE= MY DHIGEIAL EIGNAT0BE• REGISTRATION ! MBER,
SEAL
AND SETHIS .-40 DAY OP $OVEMHP IS • D. 204`2.
CERTIFICATE OF PURPOSE OF PUT
OF LEND�AND DOES NOT CRUSE PARCEL I OR PARCELS
ROAD OR CHANGE 1N E STTNG MELT.
11I oJO5 S�•
DATE O
CERIIII
DIM OP YONTGOIiPBY COUNTY
CERTIFY THAT TIE YAP OR FIAT TO WHICH TIES
CER'ffICATION 6 EFFUSE MEETS ALL STAMMER
REG0IDF]BNTS FOR RECORDING.
DATE
�n y D a
REVIEW OFFICER
1191'35'28'V
106,66'
21
STELE VAX
wawa vax
TOT 28
/
/
EXCEPTION
TO LOT B
225/997
�\ 0
\ off,
\ \ \i
\ \0IN
4,
/
/
/
/
/
LOT 22
I., N41.25'04TE
3500'
LOT 21
0.57 ACRES
RESERVED
EIP 0.27 ACRES
PARCEL "F"
0.49 ACRES
582'21'09'V
21122
NOTES:
'ear'
LT PDINT
IRS SET AT
! STATION 1+45
1. Roo PAOIOIRa woo. m Axe ASR ALL FAmio:4 Mart K TAR
410 KAM.. or RECORD MOO WINE LIM OF Oa PUT.
a. 1TERL AM 10 LW krommorrs WT. SRO IR. OF M.O.
LEGEND
• � fN9K Nx Mx
O ® DRUM MY "R
FA- 0F1100tl unnvs
LOT B
0.71 ACRES
t \ Cbtt 6R~.OT
39.2
EB \\
LOT 20
0.50 ACRES
EP
NNE 10/97 D. ALIEN
5
FP
LOT 19
SR 110
NC /011731
VICINITY MAP
TITLE REFERENCE
D® BOOK 512 PAGE 91
DEED BOOK 442 PAGE 735
WP BOOK 7 PALE 1
RONTG048RY COUNTY. MORIN CAROLINA
JUD'E1D.0/97ALLEN
O
0.
SURVEY OF
LOTS 20, 21, B,
PARCEL "F", &
RESERVED LOT
MAP B, SECTION 6, EMERALD SHORES
PEE DEE TOWNSHIP, MONTGOMERY COUNTY,
NORTH CAROLINA
OCTOBER 21, 2005 SCALE 1" = 40'
GRAPHIC SCALE
I'N FEET )
1 inch - 40 0
OFKoc WONTNAG Moe
ROAD
(aiMONO, 0. L 27.6

Montgomery County Health Department
Environmental Health Section
Applicant Tillery Land LLC Permit Number: 20I8055
Owner: Tillery Land LLC PIN #: 657414442765
Proposed Use: House Water Supply Public
Subdivision or SR Emerald Shores- Emerald Shores Rd Lot #: 20 Section #: 6 Map #: B
IMPROVEMENT PERMIT
System: New Projected Design Flow: 360 GPD Type of Wastewater: domestic
# of Bedrooms: 3 # of Occupants: 6 max Basement: Yes Basement Fixtures: Yes # of Employees: # of Seats:
Proposed Wastewater System Type:
Proposed Repair System Type:
Pump Conventional
LTAR for Initial System: .300 GPD/Sq. Ft.
GPD/Sq. Ft.
IMPROVEMENT PERMIT CONDITIONS: ***SEE ATTACHED SITE SKETCH
LIAR for Repair System:
Permit issued for 3-BR Residential
System Type: Pump Conventional
The issuance of this Improvement Permit by the Montgomery County Health Department in no way guarantees the issuance o lot& rpernats Tlx permit holder is responsible fcr checking with
appropriate governing bodies in meeting their rcgturenments, This permit is a site approval for the future installation °fan an -site wastewater system and is siimject to revocation if the site plans or
intended use changes from those shown above oron the application This Improvement Permit must be accompanied by a construction authorization prior to obtaining any building permits and
before the wastewater system is installed. This}rtlprovemenalid for a peric 1 of five years iron the date of issuance unless otherwise ncted.
Authorized State Agent:
eak Date: y/i'� ier
AUTHOR I' TION FOR WASTEWATER SYSTEM CONSTRUCTION
(Required for Building Permit)
The comtnietior mid insiallatim requirements of Rules .1950, .1952, .1954, .1956, .1937, .1958, and .1959 of Title I5A Subchapter I8A of the North Carolina Administrative Code are
incorporated by reference into the permit and shall be met Systems shall be installed in accordance with the attached system layout
System: New Projected Design Flow: 360 GPD ***SEE ATTACHED SITE SKETCH
Proposed Wastewater System Type: Pump Conventional
Proposed Repair System Type:
Septic Tank: 1000 gallons Pump Tank: 1000 gallons Trench Length: 400 feet Max Depth: 24 inches
Trench Width: 36 inches Trench Spacing: 9 feet Total Stone Depth: 12 inches Extra Soil Cover: 0 inches
CONSTRUCTION AUTHORIZATION CONDITIONS:
Plumb out low side of house in area that will accommodate basement plumbing. Pump to top of approved soil area for system installation. Improve ditch along front of
property and direct water to left side of property as shown on permit illustration, Property lines and corners shall be clearly marked prior to system insatllation.
This Authorization For Wastewater System Cmstmction is valid for a period equal to the period of validity of the Improvement Permit, not to exceed 60 morihs. (1) Wastewater system
construction and installation must meet all conditions and specifications as set forth in the Improvement Permit, Construction Authorization, and the attached site sketch with system details.
Cmstructbn and installation must also meet all requirements set forth in the Rules Governing Sanitary Sewage Collection, Treatment, And Disposal Systems and any other applicable rules
and laws. (2) The wastewater system shall not be covered or placed into use until inspected by the Montgomery County Health Department and an Op:mtire Permit issued. (3) Any
alteration in site or soil condition (includintg location of structures and appurtenances) or modifications in use, wastewater Clow, cr wastewaterchnracteristitsas specified in the associated
Improvement Permit and application, may subject this Authcrizat ion and associated permit(s) to revocation,
**If applicable:
I understand this Improvement Permit and/or Construction Authorization is different from the original requests on the
relevant application. I accept the specifications of this permit, including the site sketch.
Applicant/Legal Representative Signature: Date:
Authorized State Agent:
Date: