20230913 Ver 1_More Info Received_20230929

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State of North Carolina
Department of Environment Quality
Division of Water Resources
1SA NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 09-2020
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fe�: should be sent to:
If sending vin US Postal Service If sending via delivery service (UPS, FedEx, etc.)
Paul Wojoski Paul Wojoski
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
NOTE: Before submitting this form, please ensure you have submitted the Pre -Filing Meeting Request
Form as we will not be able to accept your application without this important first step. The Pre -Filing
Meeting Request Form is used in accordance with 40 C.F.R. Section 121.4(a) which states "At least 30
days prior to submitting a certification request, the project proponent shall request a pre -filing
meeting with the cert fying agency." In accordance with 40 C.F.R. Section 121.5(b)(7), and (c)(5), all
certification requests must include documentation that a pre -filing meeting request was submitted to
the certifying authority at least 30 days prior to submitting the certification request. Click ': to read
more information on when this form is needed prior to application submission or - to view the
form.
Attach documentation of Pre -Filing Meeting Request to this application.
Date of Pre -filing Meeting Request: (required)
(required)
R,; s
A. Applicant I
1. Owner
Name:
Mailing
Telephone
E-mail Add
Version
[15A NCAC 02H .0502(a)l
(if
�I 1 Fax Number:
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7. Will work be corducted from land? From water?
8. Total amount of impacts below the normal pool lake level / Normal ater Level
Permanent impacts (including all excavation, backfili, rip rap, retaining walls, etc.) in square feet:
? (--L Ir - rn -
Tem ovary impa its in square feet:
9. Total amount of impacts above the normal pool lake level / Normal Water Level and 50 feet
land -ward
Perrmaannenntt impcarts (in ding back fill,
C + n
rap, retaining walls, etc.) in square feet:
Te porary impacts (temporary clearing, construction corridor) in square feet:
10. Please describe fie vegetation above the normal pool lake level/ Normal Water Level and 50
to be impacted (number of trees, for instance):
11. Signature
By signing below, I, as the project proponent, certify to the following:
The project proponent hereby certifies that all information contained herein is true,
accurate, and complete to the best of my knowledge and belief
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
Owner/Agent's Signature' [ q 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 a ny 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: 55GP 09-2020 Page 3 of 5

Lake
(At Full Pond/ Normal Water Level
2
k
ve,`U-)
V
Side View
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Sid
FORM: SSGP 09-2020 Page 5 of 5

(At full Pond/ Normal Water Level)
I Pond/ Normal
Shoreline
Plan View
Lake
(NFJIFatl/X IWrter�
FORM: SSGP 09-2020