20230365 Ver 1_Shoreline Stabilization_20230309

Shoreline Stabilization Application Form
NORTH CAROLINA
Environmental Qualify
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 3/6/2023
submitted on: *
Owner Information:
Name: *
Email:*
Phone Number:
Mailing Address: *
Keith Rossi
[e-mail]
[phone]
(xxx)xxx-xxxx
Street Address
5909 Providence Glen Road
Address Line 2
City
Charlotte
Postal / Zip Code
28270-3722
Is there an agent working on the project? * Yes
No
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name: *
137 Arrowwood
State / Province / Region
NC
Country
US
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:
Latitude:*
35.264170
Longitude: *-80.079910
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 *
Please use the diagram at the link below:
https://edocs.deq.nc.gov/WaterResources/0/edoc/616616/Shoreli ne%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.)
4. Location of the property (where work is to be conducted)
Nearest Town:* Mt. Gilead
County: * Montgomery
Lake/ river/ ocean adjacent to Lake Tillery
property:
Subdivisions name or site address:*
Tillery Tradition
Include phase/lot number

Directions to site: *
Albemarle
North Carolina
Head east on W Main St toward S 1st St
3.3 mi
Continue onto NC-24 E/NC-27 W/NC-73 W
Continue to follow NC-24 E/NC-27 W
5.0 mi
Turn right onto NC-73
1.1 mi
Turn right onto Lillys Bridge Rd
0.6 mi
Turn right onto Tradition Dr
0.7 mi
Turn right onto Arrowwood Dr
0.1 mi
137 Arrowwood Dr
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. New House on Vacant Lot
Residential, undeveloped, etc.
6. Property Size
1.56
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
Owner wants to build a new 1200 sq ft boat dock and install 180' rip rap 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.)
370
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.)
555
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 Picture
Sketch: BRN3C2AF4E6BFD3001013.pdf 765.31KB
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
• $570.00 for impacts to lake (below normal water level) of greater or equal to 1 acre
By digitally signing below, I certify that:
• 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");
d 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:*
Signature:
Jeffrey T Page
eul r/,1&
Submittal Date: 3/6/2023

Initial Review
Is this accepted into the review process?* Yes 0 No
Project Number:* 20230365 Version:* 1
Select Reviewer: * Andrew Pitner:[e-mail]
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

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VICINTY MAP
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NOTES;
1 BOUNDARY PREDICATED ON EXISTING
MONUMENTATION FOUND IN THE FIELD.
2 AREA COMPUTED BY COORDINATE COMPUTATION,
3 PROPERTY IS NOT LOCATED IN A FLOOD
HAZARD AREA,
4 THIS PROPERTY IS IN A COUNTY WHICH
REGULATES THE SUBDIVIDING OF LAND.
5 THIS IS A SURVEY OF AN EXISTING PARCEL
OF LAND.
Stone seawall U shoreline N 7f S"E IRON PIPE
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0 CM - CONCRETE MONUMENT
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— — ADJACENT PROPERTY LINE (NOT 5uRvEYEO)
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BUILDING SETBACKS
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I, George W, Simpson, certify that this
MOP wos drawn from an actual purvey
made under my supervision, that the
error of closure as calculated by�r►frrri�i
I�titudes and ddapertures is 1:10,000+, `o' GaR�rf��
that the baundones not surveyed are �;.••
shown as bro n lines, and the ❑n ul + BSSI ' %
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Stamped Concrete
COURSE RADIUS CHORD CHORD BEARING
C-1 50-00' 40.67' S 49'25'14"W
C� L__J (y A I� Y SURJEY of
PROPERTY oFRT 8c 6IA111 JOHNSON
LOT IN _ PU kE Twr., MONTGOMEAY Co.. NC
IN THE city of MT. GILEAD ON ARROWWOOD ROAD
HOUSE No. - IN BLDCK No. ` ON MAP OF TILLERY TRAbITTrN
MAP RECORDED IN CABINET D . SLIDE 22`C . DEED RECORDED IN
BOOK 615 PG 412 wrE of THE: REWTER OF Dam
SURrf7 Fof2, ROBERT & DIANI JOHNSON
SCALE: 1' - ELATE )AN. 22, 2019
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SIMPSON SURVEYING
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MT. GILEAD, NC 27306
<910] 220-4000
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Plan View
Full Pond/ Norm�al Water.
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it r�crsury
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FORM: SSGP 09-2020 Page 4 of 6

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FORM. SSGP 09-2020 Page 5 of 6

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