20240297 Ver 1_MNT Base LLC Nate Albers DWR_20240221

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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 -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 -flung 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: �` /� �9 G (required)
DWR ID # Version (if applicable)

A. Applicant information [
1. Owner Information
!Name:
Mailing Address:-%�s'%l c� d?4�
Telephone Number. ��/ ��-�T, Fax Number:'z�;,
E-mail Address:
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:
S. Project Information
"M
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 (wee work is to be conducted)
County: NearestTown:--
Lake/ river/ ocean adjacent to property:
Property size (acres): _ j'h'
Subdivision name or site address (include phase/lot number): /-G;F SLUE% Z Gfi��
Directions to site - please include road names and numbers, landmarks, etc.:
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Latitude (in decimal degrees)5� ���✓ t Longitude(decima/digrees) degrees)__,:,, d, '
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5. Describe the existing land use or condition of the site at the time of this application (residential,
undeveloped, etc.): i2�ibh�iys7,k_
6. Describe proposed work (include discussion as to how hardening of shoreline has been avoided, or
why it is necessary): 6ltc,7,_ps Si��<Cr� T/�i� !r' 7 1 UZ>
!I<,k4- y2:f' iy
7. Will work be conducted from land?[ From waterV
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:
Temporary impacts in square feet:
GZ f
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:
/ p C -
Temporary impacts (temporary clearing, construction corridor) in square feet:
%5—&C_5
10. Please describe the vegetation above the normal pool lake level/ Norrpal Water Level and 5€3 feet
landward to be impacted (number of trees, for instance):
r > %G A6;eG%1i i6 G Gf 4L;­: surer
11. Signature
By signing below, 1, 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* [
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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
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