MNT Base LLC Nate Albers DWR

is �,l 1 r;L
.:rn,i!-o;t r; r.•r^: tr-.'v'"tt � iir
State of North Carolina
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 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
For electronic submittals, please see the
if sending via delivery service (UPS, FedEx, etc.)
Paul Wojoski
DWR— 401 & Buffer Permitting Branch
512 N. Salisbury Street
Raleigh, NC 27604
For GP80 Applicants Only:
Additional requirements for 401 Certification Applications have resulted from the reinstatement of
the Trump Administration's [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 -ding
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- 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:
posted a on their
. The EPA has also
webpage for more information
Attach documentation of Pre -Filing Meeting Request to this application.
Date of Pre -Filing Meeting Request: a e ` (required)
DWR ID # Version (if applicable)
O=F�rtmen o;frrtrormtnG OUYb -

A. Applicant Information
1. Owner Information
Name: ?'��Sg ' ,- .1 7�
Mailing Address: y7 ✓�
Telephone Number. i22 3 : VVtjg Fax Number:
E-mail Address: ` , Y
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:
Name -
Company Affiliation:
Mailing Address:
Telephone Number:
E-mail Address-
B. Project Information [
Dk)
I. 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.
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: ^�Jl'/�st? G�'� Nearest Town:
Lake/ river/ ocean adjacent to property: Gig! l G
Property size (acres): _ ��
Subdivision name or site address (include phase/lot number): G177:6S
Directions to site - please include road names and numbers, landmarks, etc.: 167,;(%
its c+ -li.S Z f.' V_11f7 % 0 . '
Latitude (in decimal degrees)_ =�'117 ` Longitude(decima/ degrees) � yj! t'

5. Describe the existing land use or condition of the site at the time of this application (residential,
undeveloped, etc.): aib6iuj7,9-L
6. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary):__,6!/,p�%H�s
7. Will work be conducted from land?(] From water?W
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:
1. s6" r
Temporary impacts in square feet:
9. Total amount of impacts above the normal pool take level / Normal Water Level and 50 feet land-
ward
Permanent impacts (including back fill, excavation, rip rap, retaining walls, etc.) in square feet:
i v
Temporary impacts (temporary clearing, construction corridor) in square feet:
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):
;__CI 13.E_ cd1/i i� __. L4—w Gf % �tii� j12z
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* [ J 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

IM:: r4-!71V
.5yvo 6 Mlat
IV
r 104
_3
vo#
f Lem

�.
IL
go
• _. .ass--- -a.,
lew
Won"- �'`'
PIP
-
-
_,dW..,,— _ _
_

r M ,
LAW
I
w�Il ACA&L,
4
J _ n
y �
.fib.•-ti Y ,�:
�► 1p
` _
_� I r fieAt
400
J '
los
+ —
.. V \ �.�J.. .r3e .A.>•L..— �_,r�. R •A^f. v" ... � ...1.•. �iilR< M t j4 -r rd.. •

AIF

ANG
v 6'
r? f.AK
M-
A
e
71'
stir
r
>•
r