01-Shoreline Form.pdf

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
NORTH CAROLINA State of North Carolina
Environmental Quality
Department of Environment Quality
Division of Water Resources
15A NCAC 02H .0500 — Water Quality Certification, Shoreline Stabilization
Shoreline Stabilization Application Form
FORM: SSGP 04-2022
A complete copy 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.)
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
For electronic submittals, please see the Shoreline Stabilization Application Form.
For GP80 Applicants Only:
Additional requirements for 401 Certification Applications have resulted from the reinstatement of
the Trump Administration's Clean Water Act Section 401 Certification Rule [40 C.F.R. Section
121.4(a) and 121.5(b)(7), and (c)(5)]. This rule requires that 401 applicants request a pre -filing
meeting at least 30 days prior to submitting their 401 application. In turn, the Federal Rule requires
that applicants include documentation of their pre -filing meeting request in their 401 Certification
application.
DWR has developed a Pre -Filing Meeting Request email address to accept the federally required
pre -filing meeting request. Click here: [e-mail] to send your request. In response,
you will be emailed a confirmation receipt of submittal. This confirmation receipt email must then
be submitted with your PCN application.
All 401 applications received after April 6, 2022 that do not have documentation that a pre -filing
meeting request was submitted at least 30 days prior to submittal of a 401 Certification application
will be returned as incomplete. Additional information regarding the pre -filing meeting
requirement may be found here: https://deg.nc.gov/about/divisions/water-resources/water-
auality-Dermittine/401-buffer-Dermittine/application-forms-helD-documents. The EPA has also
posted a Q&A document on their CWA Section 401 Certification webpage for more information
Attach documentation of Pre -Filing Meeting Request to this application.
Date of Pre -Filing Meeting Request: 08/20/2023 (required)
DWR ID #
Version (if applicable)
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North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919.707.9000

A. Applicant Information [15A NCAC 02H .0502(a
1. Owner Information
Name: Planishek Development & Construction. LLC
Mailing Address: 7679 Rabbit Circle
Denver, NC 28037
Telephone Number: 704-582-2156 Fax Number:
E-mail Address: [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:
http://www.saw.usace.army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf)
Name:
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address:
B. Project Information [15A NCAC 02H .0502(a) & (b
Fax Number:
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.
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)
County: Lincoln Nearest Town: Denver, NC
Lake/ river/ ocean adjacent to property: Lake Norman
Property size (acres):.85
Subdivision name or site address (include phase/lot number): West Bay
Directions to site - please include road names and numbers, landmarks, etc.: From 16, Turn on
Webbs Rd, right on Burton Lane, Left on Bay Pointe Drive
Latitude (in decimal degrees) 35.515 Longitude (decimal degrees)-80.967
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North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919.707.9000

5. Describe the existing land use or condition of the site at the time of this application (residential,
undeveloped, etc.): Residential, No Home. Existing Pier & Rip Rap.
6. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary): 1) Repair rip rap, 2) Remove tree falling towards pier in Rip Rap,
grubbing/pruning of buffer area, 3) water/electric/irrigation line to pier, 4)New pervious walk to
pier.
7. Will work be conducted from land? ® 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:
NA
Temporary impacts in square feet:
NA
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:
Walkway=200 sf (50' x 4')
Rip Rap Repair = 181 LF x 3' = 543 sf (repair, not new install)
Temporary impacts (temporary clearing, construction corridor) in square feet:
300 Ft +200' = 500' For temporary access.
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): Mixture of hardwoods,
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 reauest within the aoolicable reasonable period of time
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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.
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Lake
(At Full Pond/ Normal Water Level}
Full Pond/ Nir,ilWater Level _ _ _ - _ _ _ _ _ _ _ _
Shoreline
Plan View
Lake
(At Full Pond! Normal water -e I)
Existing Dock
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