20221383 Ver 1_Shoreline Stabilization_20221006

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 10/5/2022
submitted on: *
Owner Information:
Name: *
Email: *
Phone Number:
Mailing Address: *
Matthew Malone
[e-mail]
[phone]
(xxx)xxx-xxxx
Street Address
21304 Norman Shores Drive
Address Line 2
City
Cornelius
Postal / Zip Code
28031-6694
Is there an agent working on the project? * Yes
No
Agent/Consultant Information
State / Province / Region
NC
Country
US
Name:* Dean Fisher
Company Affiliation: * Lake Norman Custom Dock & Pile Driving, Inc
Email: * [e-mail]

Phone Number:*
Mailing Address:*
[phone]
(xxx)xxx-xxxx
Street Address
PO Box 1439
Address Line 2
City State / Province / Region
Denver NC
Postal / Zip Code Country
28037 United States
A signed and dated copy of the Agent Authorization letter:*
Simple Agent Form.pdf 379.38KB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:*
Malone 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
Upload Map: 21304 Norman Shores Dr - Google Maps.pdf 648.94KB
Latitude:*
35.501821
Longitude: *-80.880954
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*
drawing.pdf 39.48KB
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.)
imageO.pdf 885.71 KB
image l .pdf
image2.pdf
883.93KB
910.95KB
4. Location of the property (where work is to be conducted)
Nearest Town: * Cornelius
County: * Mecklenburg

Lake/ river/ ocean adjacent to Norman
property:
Subdivisions name or site address: *
21304 Norman Shores Dr Cornelius, NC 28031 / lot 41
Include phase/lot number
Directions to site: *
Head southeast on NC-16 Business S. Turn left onto Hagers Ferry Rd.
Turn right at the 1st cross street onto N Pilot Knob Rd. Turn left onto NC-
73 E. Turn left onto W Catawba Ave. Turn left onto One Norman Blvd.
Turn right onto Knox Rd. Turn left onto Torrence Chapel Rd. Turn right
onto Norman Shores Dr. House is on the right
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: *
Manicured lawn.
Residential, undeveloped, etc.
6. Property Size
0.310
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
On left side of dock grading, clearing and backfill along shoreline.
Construction of 4x60ft wooded T&G seawall with 6x6 posts. Installation
and delivery of approx 2x60ft along base of wall for Rip Rap to prevent
scour. On right side of dock rip rap refresh.
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.)
240 sq ft
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.)
600 sq ft
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)
manicured lawn
Sketch:
drawing.pdf
Malone documents.pdf
Application Fee:
39.48KB
750.97KB
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):
a $240.00 for impacts to lake (below normal water level) of less than 1 acre
a $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
a I intend to electronically sign and submit the Shoreline Stabilization online form.
Full Name:* Dean Fisher
Signature:
9
Submittal Date: 10/5/2022

Initial Review
Is this accepted into the review process?* Yes No
Project Number:* 20221383 Version:* 1
Select Reviewer: * Doug Perez:eads\djperez
Select Reviewing Office: Mooresville 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

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 41 PLAN NO. PARCEL ID: 00143138
STREET ADDRESS: 21304 Norman Shores Dr., Cornelius NC 28031
Please print:
Property Owner: Matthew Malone
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Dean Fisher, President
(Contractor / Agent)
of Lake Norman Custom Dock & Pile Driving, Inc
(Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (11 different than property above):
Telephone: [phone]
We hereby certify the above Information submitted in this application is true and accurate to the
best of our knowledge.
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SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 41 PLAN NO. PARCEL ID: 00143138
STREET ADDRESS: 21304 Norman Shores Dr., Cornelius NC 28031
Please print:
Property Owner: Matthew Malone
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Dean Fisher, President
(Contractor / Agent)
of Lake Norman Custom Dock & Pile Driving, Inc
(Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (11 different than property above):
Telephone: [phone]
We hereby certify the above Information submitted in this application is true and accurate to the
best of our knowledge.
>r�
Authori d S71-q
natufre
Date: 3 / ��,
Authorized Signature
Date:

Project Name/a
Owner:
CATAWBA RIPARIAN BUFFER NOTIFICATION FORM
21304 Norman Shores Dr, Cornelius NC 28031 County: Mecklenburg '
Print Signature
Contractor/agent: Dean Fisher
Print Signature
The approval is for the purpose and design described in your application. Impacts not indicated in the
application is a violation of the Buffer Rule. Site specific work should be provided in the application. [15A NCAC
02H .0506 and 15A NCAC 02B .0243(g))
Trees are not allowed to be removed from Zone 1 of the Buffer (within 30 ft of the full pond elevation), unless
approved. Exception, those trees that are severely undermined along the immediate shoreline can be removed.
Minimal shaping and sloping along the immediate shoreline is allowed. [15A NCAC 02B .0243(6)]
Benching, grading in the buffer is not allowed. Excessive disturbance of ground cover. [15A NCAC 02B .0243 (6)]
Beaches, impervious patios, impervious walkways, etc. are not allowed in the buffer unless specifically approved
by the Division. There are limitation on size for decks. 115A NCAC 02B .0243(4) and (6)]
Work to be conducted from land must indicate an access and indicate any trees that are to be removed. The
work corridor should be described_ The approved access corridor shall be restored. Staging, spoil, construction
material must be outside the buffer. [15A NCAC 02H .0502 and 15A NCAC 02B ,0243 (4), (6), (8)]
Stormwater cannot be piped or channeled for direct discharge to the lake. All constructed stormwater
discharges must be at the natural elevation and discharged prior to entering the buffer directed as diffuse or
sheet flow at non -erosive velocities to the lake. [15A NCAC 02B .0243(5), (6)]
Acknowledgement of !Notification
i, Matthew Malone hereby state that I have been informed of the Catawba
Riparian Buffer Rule. Any work conducted in the buffer, not specifically stated in the application and approved
by the Division of Water Resources (DWR), is a violation and subject to enforcement Due diligence will be
taken such that the construction will be built within substantial compliance and intent of the 401 Water
Quality Certification and Buffer Rules, the approved plan(s) and specification(s), and other supporting
materials. _7
Signature (owner)://% Date: 3
State of North Carunna Environmental Qwli4 Water keuam es
A2N Salisbury 5treet 1611 M all Ser vic e Centcr Raleigh NC Rh9" 4,11
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