20230041 Ver 1_Shoreline Stabilization_20230110

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 12/2/2022
submitted on: *
Owner Information:
Name: *
Email: *
Phone Number:
Mailing Address: *
Duane & Mary Drinkwine
[e-mail]
[phone]
(xxx)xxx-xxxx
Street Address
642 Foster Lane
Address Line 2
City
Pittsboro
Postal / Zip Code
27312-8753
Is there an agent working on the project? * Yes
No
Agent/Consultant Information
State / Province / Region
NC
Country
US
Name: * PHILIP POLAND
Company Affiliation: * Phils Quality Construction
Email: * [e-mail]

Phone Number:*
Mailing Address:*
[phone]
(xxx)xxx-xxxx
Street Address
1 LAKE ROYALE
Address Line 2
City State / Province / Region
LOUISBURG NC
Postal / Zip Code Country
27549-9587 United States
A signed and dated copy of the Agent Authorization letter:*
drinkwine authorization form.pdf 384.44KB
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:*
Duane & Mary Drinkwine
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: 2023-01-04_082902.pdf 991.83KB
Latitude:*
35.985100
Longitude: *-78.206820
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*
plot plan 214 drinkwine.pdf 1.24MB
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.)
drinkwine pic.pdf 3.75MB
4. Location of the property (where work is to be conducted)
Nearest Town: * Bunn
County: * Franklin
Lake/ river/ ocean adjacent to Lake Royale
property:

Subdivisions name or site address: *
241 Sagamore Drive Louisburg NC 27549 lot#1330
Include phase/lot number
Directions to site: *
From Cheyanne Dr @stop sign go straight @ next stop sign turn left onto
Sagamore Dr and 241 Sagamore Dr is on your 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: *
Undeveloped
Residential, undeveloped, etc.
6. Property Size
0.57
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
Seawall to stop erosion of shoreline also including a dock and boathouse
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.)
462
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.)
456
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)
20 trees 60sq.ft.
Sketch: plot plan 214 drinkwine.pdf 1.24MB
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:* Philip Poland
Signature:
Submittal Date: 1/4/2023

Initial Review
Is this accepted into the review process?* • Yes No
Project Number: * 20230041 Version: * 1
Select Reviewer: * Zachary Thomas:eads\ztthomas:[e-mail]
Select Reviewing Office: Raleigh 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

EXAMPLE AGENT Ail T HORiZATION FORMI `. .
Proaerw Legal Descrialon:
020417
Parcel ID.
1330
Lot No. (if applicable) —_Plan No. (if applicable)
241 Sagamore
Street Address(ff apPlacacie;' Dr .
z; onerw Finer.
Duane and Mary Drinkwine
Owner ltlarne (print):
propeee}r e)rvner s Address (if different than the above?:
642 FOSTER LANE Pittsboro, NC 27312
Owner Signature:
The above registered property owners ofthe above properly, do hereby authorize
Phil Poland Phil's quality construction
of
Agent ma -me Agent Company Name (ifappli-able}
to act on tray Behalf and take all actions neces ary for the application, processing, issuance and
ascept_.nce of -this permit, cerdfication or authorization including all standard and special conditions
attached.
I hereby certify that the above information submitted on this form and apprication is true and accurate
to tide k:st of ar•,r F.nowl edge. (� I 1/�
Authorized agent Name / Company: � 1�ti�) 1'/1 \ A / I� h, � S � 1 � 1I ,
� n S C-4,
Autha ;zed Agent Signature'.
Date:

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