20141145 Ver 1_Shoreline Stabilization_20141031

2 0 1 4 1 1 4 5 State of North Carolina
DWR Department of Environment and Natural Resources
Division of Water Resources
Division of Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10 -2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
� LP, r�
Raleigh, NC 27699 -1617 ,,. _
OCT 3 Y 2014 'J
I. Applicant Information [15A NCAC 02H .0502(a)] j
1. Owner Information DENR - WgTER REESSOURCES
401 & BUFFER PERMITTING
Name: Micheal J Koroly
Mailing Address: 12622 Framfield Ct
Huntersville N C 28078
Telephone Number: 704 - 947 -2891 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. mil / Portals /59 /docs /regulatory /regdocs /Permits /SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name Butch Brown
Company Affiliation: Brown's Construction
Mailing Address: 104 Dogwood Lane
Mt Gilead N C 27306
Telephone Number: 910 - 439 -1384 Fax Number: same
E -mail Address: [e-mail]
Person to receive the Certification Approval: Butch Brown
II. Project Information [15A NCAC 02H .0502(a) & (b)J
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.
FORM: SSGP 10 -2013 Page 1 of 4

�1
` 4
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 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 yard stick, shovel handle, etc.)
4 Location of the property (where work is to be conducted)
County. Montgomery
Nearest Town: Mt Gilead N C 27306
Subdivision name or site address (include phase /lot number)- fairway Shores
see map attached
Directions to site - please include road names and numbers, landmarks, etc..
see nap attached
Latitude (in decimal degrees) Longitude (decimal degrees)
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.). residential
6 Property size (acres) % of acres
7. Lake/ river/ ocean adjacent to property. Lake Tillery
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): construction of a treated lumber sea -wall 150 ft lonp,
and 3 ft NO with 2 inch stone to be placed on the shore line side of the sea -wall and rip -
rap on the lake side
9. Will work be conducted from land? X❑ 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
150 ft lone 2 ft below the water line
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc ) above the normal pool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres 150 ft long and 2 ft above the water line
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) no trees lawn
Grass only
FORM SSGP 10 -2013
Page 2 of 3

FL
Norma
SI
La ke
(At Full Pond /Normal Water Level)
QX 1� ft*
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft) *:
1. All proposed vegetation clearing
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
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: 55GP 10 -2013 Page 3 of 3

1 of 1
10 -11 -14
Brown's Construction
104 Dogwood Lane
Mt Gilead N C 27306
910 -439 -1384
I Michael J Koroly give Butch Brown of Brown's Construction my
permission to act as my agent in securing permission, permits and
construction to be done on 508 fairway Shores Rd Mt Gilead N C 27306
DatetC�- �'� �►�-(
Mich el L Koroly

1 of 1
Brown's Construction
104 Dogwood Lane
Mt Gilead N C 27306
910 -439 -1384
10 -22 -14
This is for the proposal of the construction of a 150 ft. x 3 ft Treated lumber sea -wall
with rip -rap to be installed on the lakeside of the sea -wall and 2 inch stone on the
shoreline side of the sea -wall to meet Duke Energy speciation's and N C building codes
Butch Brown
10 -22 -14

Montgomery County, NC Print Map
-rte • ' �'
Page 1 of 2
Montgomery County, NG
Disclaimer: The information contained on this page is taken from aerial mapping, tax mapping, and public records and is NOT to be construed or
used as a survey or'legal description'. Only a licensed professional land surveyor can legally determine precise locations, elevations, length and
direction of a line, and areas.
Parcel Number: 6584 17 00 4078
Name: KOROLY, MICHAEL J. &
Address 1: VIRGINIA R.
House* 508
Road Name: FAIRWAY SHORES
Road Type: RD
Address 2: 12622 FRAMFIELD CT
Address 3: HUNTERSVILLE, NC 28078
Parcels
Deed Book: 556
Deed Page: 469
Lot Number: BLK C (WESTERN PT). M/3
Legal Description: FAIRWAY SHORES
Sale Month: 02
Sale Year: 06
Total Market Value: 404700
Land Value: 124208
Building Value: 275265
Year Built: 2000
Appraisal: 01
Attributes at point: I_v: 54u 1.30, c: I oouj-+u
Fire Districts Townships Proposed Voting Commissioner's Districts
Name: Mt. Gilead Name: PEE DEE District: 1
Zoning
Zoning: Residential 1
City:
Watersheds
Class: WS -IV
Name: Lake Tillery
River Basin: Yadkin
init: start
Voting District Precincts
Name: PEE
Anderson & Associates. Inc. http /hnwr andassoc.com
httn:// arcais. webv-is. net/nc/Montgomery /printable.asp 10/5/2014
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