20240057 Ver 1_Shoreline Stabilization_20240108

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*
Owner Information:
Name:
Email:
Phone Number:
Mailing Address:
[e-mail]
Please provide an email address for payment and requests for more information here.
Robin Poole
[e-mail]
[phone]
(xxx)xxx-xxxx
Street Address
7018 Gold Dust Lane
Address Line 2
City
Indian Trail
Postal / Zip Code
28079-4289
Is there an agent working on the project?* Yes
No
Agent/Consultant Information
......... ......... ......... ......... .........
Name: * Anchored Design
Company Affiliation: *
Email: *
Phone Number:*
owner
alexrickettsI [e-mail]
[phone]
(xxx)xxx-xxxx
State / Province / Region
NC
Country
Us

Mailing Address: *
Street Address
49470 Wood Land Drive
Address Line 2
City
Norwood
Postal / Zip Code
28128-6440
A signed and dated copy of the Agent Authorization letter:
Agent Authorization Form SIgned.pdf
Link to: Sample Agent Authorization Form
Project Information [15A NCAC 02H .0502(a) & (b)]
Project Name:* Poole Shoreline
State / Province / Region
NC
Country
US
770.48KB
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: * 35.240636
Street Address
1149 Emerald Shores Road
Address Line 2
City
Mt Gilead
Postal / Zip Code
27306-9181
State / Province / Region
NC
Country
US
Longitude: *-80.087470
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:Hedocs.deq.nc.gov/WaterResources/o/edoc/616616/Shoreline%2OLayout.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.)
I... .
4. Location of the property (where work is to be conducted)
Nearest Town: * Mount Gilead
County: * Montgomery
Lake/ river/ ocean adjacent to Lake Tillery
property:
Subdivisions name or site address: * Emerald Shores
Include phase/lot number
Directions to site: *
Off of Lilys Bridge Road turn onto Emerald Shores Road, follow back, property will be on the left.
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
Residential, undeveloped, etc.
6. Property Size .49
Acres
7. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):
Stabilize Natural Shoreline along area where new dock is to be built.
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.)
150
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.)
150
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)
Less than 10 Trees
Sketch:
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 $323.00 for impacts to lake (below normal water level) of less than 1 acre
1 $767.00 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
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.
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');
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 1 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:* Alexander Paul Ricketts
Signature:
G&z14RArra
Submittal Date: 12/27/2023

Initial Review
Is this accepted into the review process?* Yes No
Project Number:* 20240057 Version: *
Select Reviewer: *
Select Reviewing Office
Has payment been received?*
What amount is owed?*
Chad Turlington:chad.turiington
Fayetteville Regional Office - [phone]
No Payment Needed
Fee Received
Need Fee - send electronic notification
$240.00 $570.00
$323.00
$767.00