20230541 Ver 1_information for 401_20231102 (2)

COOPER
nor
HAEL S. REGAN
tare
4NIEL SMITH
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NORTH CAROLINA
Environmenta/Quality
State of North Carolina
Department of Environment Quality
Division of Water Resources
1SA NCAC 02H .OS00 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 09-2020
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
Paul Wojoski
DWR-401 & Buffer Permitting Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
If sending via delivery service (UPS, FedEx, etc.)
Paul Wojoski
DWR-401 & Buffer Permitting Branch
512 N. Salisbury Street
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 certifying 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 here to read
more information on when this form is needed prior to application submission or here to view the
form.
Attach documentation of Pre -Filing Meeting Request to this application.
Date of Pre -filing Meeting Request: I_ f (required)
DWR ID
Version (if applicable)
A. Applicant Information 115A NCAC 02H .0502(a)
1. Owner Information
Name:
Mailing Address:
Telephone Number:
E-mail Address:
b �U �`ti0�0`1Fax Number:
I Jpq+rtclLbr _-, —E? (ttaA ,Cow
less%North Carolina Department of Environmental Quality Divisionof Water Resources
�E 512 North Salisbury Street 1 1617 Mail Service Center Raleigh. North Carolina 27699-1617
w Lkb 9197079000

7. Will work be conducted from land? El From water?
8. Total amount of impacts below the normal pool lake level / Normal Water Level
Permanent impacts (including all excavation, backfill, rip rip, retaining walls, etc.) in square feet:
i '4-
impacts in square feet:
9. Total amount of impacts above the normal pool lake level/ Normal Water Level and 50 feet
land -ward
impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
clearing, construction corridor) in square feet:
10. Please describe the vegetation above the normal pool lake level/ Normal Water Level and 50
feet la d and 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
2 1 2
Owner/Agent's Signature' [15A NCAC 02H .0502(f)] Date
'Agent's signature is valid only if an authorization letter from Me owner is provided.
12. Please approximately sketch the following information on this plan and prvv/de d/menslons 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 Hill 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 Fond/ Normal Water Level
elevation
FORM: SSGP 09-2020 Page 3 of 5

Lake
(At Full Pond/ Normal Water Level)
k
Ful' Pond/ Normal Water Level b (� D
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Shoreline ^ at1I � D
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Plan View
Lake
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Full Ppd/N lWAKL
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Ripop
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Plan View
Existing Dock
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FORM: SSGP 09-2020 Page 4 of 5

<- �7
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J
Lake I �k 1�216w
(At Full Pond/ Normal Water Level)
d
— c
Ev
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0
c
Side View
7
LL
3 ft below full pond water level A ftabove full pond water level 2 ft. additional clearing
'if necessary
FORM: SSGP 09-2020 Page 5 of 5