20230169 Ver 1_Shoreline Stabilization_20230201

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 1/27/2023
submitted on: *
Owner Information:
Name: *
Email: *
Phone Number:
Mailing Address: *
Blake King
[e-mail]
[phone]
(xxx)xxx-xxxx
Street Address
15 Moortown Ct
Address Line 2
City
Durham
Postal / Zip Code
27713-6124
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: * King Riprap
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: Map.pdf 576.13KB
Latitude: *
36.507361
Longitude: *-79.073122
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*
SSGP 02-2017 Shoreline Form final - King
5.61MB
PDF 1-17-23.pdf
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.)
SSGP 02-2017 Shoreline Form final - King
PDF 1-17-23.pdf
5.61MB
4. Location of the property (where work is to be conducted)
Nearest Town: * Roxboro, NC
County:* Person
Lake/ river/ ocean adjacent to Hyco Lake
property:
Subdivisions name or site address: *
The Reserve
Include phase/lot number
Directions to site: *
From Roxboro, NC - Take Hwy 57N to Hyco Lake-, cross 3 bridges to
Hyco Lake. After crossing third bridge, go approximately 1/2 mile and
turn right onto Zion Level Church Rd. Go approximately 2.7 miles and
turn left on Pinesborough Estate Road. Go 1.2 mile and turn left onto
Estate Rd. Go approximately .8 miles and turn left into 743 Estate Rd.
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: *
Residential Lot
Residential, undeveloped, etc.
6. Property Size
1.39
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
Apply riprap along the eroding shoreline to prevent future damage. The
larger wake boats have done considerable damage to the shoreline. The
shoreline will continue to erode if riprap is not applied. Date of proposed
work will be as soon as application is approved to mitigate future damage
to shoreline.

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.)
500
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)
Little vegetation will be disturbed. Most of the area is grass/dirt at this
time.
Sketch:
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: * Donald Blake King II
Signature:
Submittal Date: 1/27/2023

Initial Review
Is this accepted into the review process?* Yes No
Project Number:* 20230169 Version:* 1
Select Reviewer: * Zachary Thomas:eads\ztthomas
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

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; y,v State of North Carolina
Department of Environment and Natural Resources
e. Division of Water Resources
Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL QUALITY FORM: SSGP 02-2017
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent to:
If sending via US Postal Service If sending via delivery service (UPS, FedEx, etc.)
Karen Higgins Karen Higgins
DWR — 401 & Buffer Permitting Branch DWR — 401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information [15A NCAC 02H .0502(a
1. Owner Information
Name:
Mailing Address
Telephone Number
E-mail Address:
Donald Blake King II
15 Moortown Court
Durham, NC 27713
919-672-2116 Fax Number:
[e-mail]
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter must be attached if the Agent has
signed this application form. (A form can be downloaded here:
httD://www.saw.usace.armv.mil/Portals/59/docs/re2ulatorv/reEdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
B. Project Information [15A NCAC 02H .0502(a) & (b
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.
2. Provide a detailed site plan showing property boundaries and proposed locations of
vegetation clearing, buildings, retaining walls, docks, impervious surfaces, 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.
FORM: SSGP 02-2017 Page 1 of 3

3. Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale of
some sort- a yard stick, shovel handle, etc.) See attached photographs
4. Location of the property (where work is to be conducted)
County: Person
Lake/ river/ ocean adjacent to property: Hyco Lake
Property size (acres): 1.4
Nearest Town: Milton
Subdivision name or site address (include phase/lot number): The Reserve
Directions to site - please include road names and numbers, landmarks, etc.: Turn off hwy 57
(Semora Road) to Zion Level Church Road and continue to Estate Road. Turn left into lot 7
which is now listed as 743 Estate Road.
Latitude (in decimal degrees) 36.507361
-79.073122
Longitude (decimal degrees) 79
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Residential
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Natural shoreline exist now and is eroding. New home and
boat house is being built on site and request is to use riprap to stabilize shoreline
7. Will work be conducted from land? Fq
From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
1100 SQFT
Temporary impacts in square feet:
1100 SQFT
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
650 SQFT
Temporary impacts (temporary clearing, construction corridor) in square feet:
650 SQFT
FORM: SSGP 02-2017 Page 2 of 3

10. 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): The Lot has mostly been cleared
of trees so little to no vegetation to be disturbed 50ft landward. 2ft x 207ft
11. Signature
1-16-23
Owner/Agent's Signature* [15A NCAC 02H .0502(f)] Date
"Agent's signature is valid only if an authorization letter from the owner is provided.
12. Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
FORM: SSGP 02-2017 Page 3 of 3

Full Pond/ Normal Water
Shoreline
2.5 ft x 207ft
additional clearing
if necessary
Plan View
La ke
(At Full Pond{ Normal Water Level]
:riprap
2.5 ft x 207 ft below full pond
„•;•; 2.5 it x 207 it above full pond

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BILLING CONTACT
Donald King
743 Estate Rd
Semora, Nc 27343
Payment Date: 08/22/2022
Reference Number Fee Name Transaction Type Payment Method Amount Paid
BLDR-000414-2022 Building Permit Fee (Residential) Fee Payment Credit Card $1,644.00
743 Estate Rd Semora, NC 27343 SUB TOTAL $1,644.00
TOTAL $1,644.00
August 22, 2022 Thank you for choosing to conduct your business in Person County! Page 1 of 1

's
; y,v State of North Carolina
Department of Environment and Natural Resources
e. Division of Water Resources
Water Resources 15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
ENVIRONMENTAL QUALITY FORM: SSGP 02-2017
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent to:
If sending via US Postal Service If sending via delivery service (UPS, FedEx, etc.)
Karen Higgins Karen Higgins
DWR — 401 & Buffer Permitting Branch DWR — 401 & Buffer Permitting Branch
1617 Mail Service Center 512 N. Salisbury Street
Raleigh, NC 27699-1617 Raleigh, NC 27604
A. Applicant Information [15A NCAC 02H .0502(a
1. Owner Information
Name:
Mailing Address
Telephone Number
E-mail Address:
Donald Blake King II
15 Moortown Court
Durham, NC 27713
919-672-2116 Fax Number:
[e-mail]
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter must be attached if the Agent has
signed this application form. (A form can be downloaded here:
httD://www.saw.usace.armv.mil/Portals/59/docs/re2ulatorv/reEdocs/Permits/SAMPLE AGENT AUTHORIZ
ATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
B. Project Information [15A NCAC 02H .0502(a) & (b
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.
2. Provide a detailed site plan showing property boundaries and proposed locations of
vegetation clearing, buildings, retaining walls, docks, impervious surfaces, 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.
FORM: SSGP 02-2017 Page 1 of 3

3. Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale of
some sort- a yard stick, shovel handle, etc.) See attached photographs
4. Location of the property (where work is to be conducted)
County: Person
Lake/ river/ ocean adjacent to property: Hyco Lake
Property size (acres): 1.4
Nearest Town: Milton
Subdivision name or site address (include phase/lot number): The Reserve
Directions to site - please include road names and numbers, landmarks, etc.: Turn off hwy 57
(Semora Road) to Zion Level Church Road and continue to Estate Road. Turn left into lot 7
which is now listed as 743 Estate Road.
Latitude (in decimal degrees) 36.507361
-79.073122
Longitude (decimal degrees) 79
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): Residential
6. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Natural shoreline exist now and is eroding. New home and
boat house is being built on site and request is to use riprap to stabilize shoreline
7. Will work be conducted from land? Fq
From water? ❑
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavation, backfill, rip rap, retaining walls, etc.) in square feet:
1100 SQFT
Temporary impacts in square feet:
1100 SQFT
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
650 SQFT
Temporary impacts (temporary clearing, construction corridor) in square feet:
650 SQFT
FORM: SSGP 02-2017 Page 2 of 3

10. 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): The Lot has mostly been cleared
of trees so little to no vegetation to be disturbed 50ft landward. 2ft x 207ft
11. Signature
1-16-23
Owner/Agent's Signature* [15A NCAC 02H .0502(f)] Date
"Agent's signature is valid only if an authorization letter from the owner is provided.
12. Please approximately sketch the following information on this plan and provide dimensions for
each item:
a. All proposed vegetation clearing
b. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
c. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
d. Location of any proposed structures such as buildings, retaining walls, docks, etc.
e. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
FORM: SSGP 02-2017 Page 3 of 3

Full Pond/ Normal Water
Shoreline
2.5 ft x 207ft
additional clearing
if necessary
Plan View
La ke
(At Full Pond{ Normal Water Level]
:riprap
2.5 ft x 207 ft below full pond
„•;•; 2.5 it x 207 it above full pond

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BILLING CONTACT
Donald King
743 Estate Rd
Semora, Nc 27343
Payment Date: 08/22/2022
Reference Number Fee Name Transaction Type Payment Method Amount Paid
BLDR-000414-2022 Building Permit Fee (Residential) Fee Payment Credit Card $1,644.00
743 Estate Rd Semora, NC 27343 SUB TOTAL $1,644.00
TOTAL $1,644.00
August 22, 2022 Thank you for choosing to conduct your business in Person County! Page 1 of 1