20221603 Ver 1_Shoreline Stabilization_20221114

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 11/10/2022
submitted on: *
Owner Information:
Name: *
Email: *
Phone Number:
Mailing Address: *
Todd and Dineen Gruchacz
[e-mail]
[phone]
(xxx)xxx-xxxx
Street Address
115 Cedar Rock Lane
Address Line 2
City
Mt Gilead
Postal / Zip Code
27306
Is there an agent working on the project? * Yes
No
Project Information [15A NCAC 02H .0502(a) & (b)]
State / Province / Region
NC
Country
US
Project Name:* 115 Cedar Rock
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: 346 Plantation_Vicinity.pdf 300.52KB
346 Plantation_Survey.pdf 215.1 KB
Latitude: *
35.289810
Longitude: *-80.088900
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*
346 Plantation_Site.pdf 237.71KB
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.)
346 Plantation_Photo.pdf 410.35KB
4. Location of the property (where work is to be conducted)
Nearest Town: *
County:*
Lake/ river/ ocean adjacent to
property:
Subdivisions name or site address: *
Directions to site: *
Mt. Gilead
Montgomery
Lake Tillery
Tillery Tradition
Include phase/lot number
NC-24
North Carolina
Follow NC-210 N, NC-24 W/NC-87 N and NC-27 W to NC-73 in
Montgomery County
Continue on NC-73. Take Tradition Dr to Cedar Rock Ln
5 min (2.5 mi)
115 Cedar Rock Ln
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: *
No existing structures. New lot and house. See attached photo
Residential, undeveloped, etc.
6. Property Size
1.19
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
Want to build new 1200 sq ft boat dock and install 100' rip rap shoreline.
See attached drawing

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.)
200
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.)
500
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)
See attached photo
Sketch: 346 Plantation_Photo.pdf 410.35KB
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:
o I, the project proponent, hereby certifies that all information contained herein is true, accurate, and complete to the best
of my knowledge and belief
o 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.
o 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");
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 Shoreline Stabilization online form.
Full Name:* Jeff Page
Signature:
)J?
Submittal Date: 11/10/2022

Initial Review
Is this accepted into the review process?* Yes No
Project Number: * 20221603 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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LOCATION MAP (N,T.S,)
LEGEND
These standard symbols will
be found in the drawing.
IRF - Iron Rod Found
IRS - Iron Rod Set
IPF — Iron Pipe Found
0 CC - Computed Comer Not Set
N/F = Now or Formerly
PP = Power Pale
OHP = Overhead Power Line
N 63°17'31" E
28,58'
ZONED:
RESIDENTIAL 1
Building Set Backs
Front 30 ft.
Side 10 ft.
Rear / Lake 10 ft.
THIS MAP MAY NOT BE A CERTIFIED
SURVEY AND HAS NOT BEEN REVIEWED
BY A LOCAL GOVERNMENT AGENCY FOR
COMPLIANCE WITH ANY APPLICABLE
LAND DMLOPMENT REGULATIONS AND
HAS NOT BEEN REVIEWED FOR
COMPLIANCE WITH RECORDING
REQUIREMENTS FOR PLATS.
1
LAKE
TILLERY
� N 89"20'21" E
8g \,28.78'
4 /
1 �
w �
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19.5'
9.5'
1 �
\ � Lot 29146.5'1\�`� `�1
0,85 Ac_
11 �
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00
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0' 60'
Scale: 1" = 60
Lot 30
ra. y F-7 curlee
PIN:: fi575p7472743
CAM DEVELOPIMYNr l \ V.15
PROPERTIES INC, f� � � & C,
PIN: 657507670519 'ts "1 /
I Michael R. 1R¢ram , Cerdry That this plat
0,38 AC / 16,456 SF
was drawn under my direct supervision from
an actual survey made under ray direct
CA t�
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Site Plana of Property For:
supervision rm:.. d«d dearrip6-
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r--,ded
shown heron. That the boundaries not
surveyed are clearly indicated dashed lines
�C) Q�OFE SS
C
C t0
Richard Harrison
as
SEAL P
as drawn from information of record r
shown hereon. That the Ratio of Precision as
L-4171
Pee Dee Twsp„ Montgomery County, N.C.
calculated is 1/ ]0,000+,That this plat was
in accordance G.S. 47-30
y� O�
Located at; 346 Piatation Way
prepared with (nj as
amended, Witness my hand and Official
sufo
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For Peferonce See,
stamp or Seal.
�� ft. �\
D,B. 882, PG. 276 / P1N:657507671710
02 / 14/22
Lot ( 29 ) / P.C. E, Slide 10-B
Profession Land Surveyor
# L 4171 Date
Date:02/14/22 - Brawn Hr MRI - File

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