20230399 Ver 1_Shoreline Stabilization_20230314

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 3/7/2023
submitted on: *
Owner Information:
Name:* Todd & Darci Wash
Email: * [e-mail]
Phone Number: [phone]
(xxx)xxx-xxxx
Mailing Address: * Street Address
500 E Kesley Ln
Address Line 2
City
St John
Postal / Zip Code
32259
Is there an agent working on the project? * Yes
No
Agent/Consultant Information
Name:* Jeffrey Webb
Company Affiliation: * Jeffrey Webb Construction Inc
Email: * [e-mail]
State / Province / Region
FL
Country
USA

Phone Number:*
[phone]
(xxx)xxx-xxxx
Mailing Address: *
Street Address
PO Box 668
Address Line 2
City State / Province / Region
Troy NC
Postal / Zip Code Country
27371 USA
A signed and dated copy of the Agent Authorization letter:*
Wash authorization form.pdf
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .O5O2(a) & (b)]
Project Name: *
Wash shoreline
358.67KB
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
Property Address Lookup: *
Latitude:*
35.295220
Street Address
140 Sunset Ct
Address Line 2
City State / Province / Region
Mt Gilead NC
Postal / Zip Code Country
27306 USA
Longitude: *-80.086270
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 *
s...
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.)
s...
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: *
Hwy 73
Rt on Lilly's bridge rd
Rt on Tradition dr
Rt on Shagbark
Lt on Sunset Ct
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 underdeveloped
Residential, undeveloped, etc.
6. Property Size
1.21
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
Shoreline stabilization
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.)
800 sf
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.)
12000 sf
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)
Several pines and undergrowth
Sketch: Wash shoreline.pdf 2.06MB
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):
d $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:

d 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:*
Signature:
Jeffrey Webb
Submittal Date: 3/14/2023

Initial Review
Is this accepted into the review process?* Yes 0 No
Project Number:* 20230399 Version:* 1
Select Reviewer: * Chad Turlington:[e-mail]
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

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. _jv Z PLAN NO.
STREET ADDRESS: 1AP S. t 4L� C-1.
PARCEL ID: (vS7(, p 4I S 6/ 8 (0
IK 4. Ctf,ad WC 273 aG
Please print: DtX6 � V � � 1 as h
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
of --z-e(Lw wru cv.
(Contractor ! Agent) (Name of co sulting 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 (if different than property above):
t5co F ..Psl Ly Lvi •
Telephone: —M 5" 1 "
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature
Date:
Authorized Signature
Date:
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