20161063 Ver 1_401 Application_20161116

State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
Division of Water Resources 15A NCAC 02H.0500—Water Quality Certification,Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form 2 0 1 6 1 0 6 3
Three copies of the application (including attachments) and the application fee should be sent
to: AJ
A11%
Division of Water Resources
401 & Buffer Permitting Unit p V
1617 Mail Service Center lJ D
Raleigh, NC 27699-1617 NO V 0 4 2016
I. Applicant Information [15A NCAC 02H .0502(a)] qDI - A ER RES R e FFER PE nn s
1. Owner Information
Name: Paul D Hartley
Mailing Address: 1533 Reflection Pointe Blvd
Belmont NC 28012
Telephone Number: 704-369-9108 Fax Number:
E-mail Address: [e-mail] VtNrI �.�HmA L, G�u✓�
2. Agent/Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http://www.saw.usace.army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name: same
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Person to receive the Certification Approval: VAI 1 iI(C-1
II. Project Information [15A NCAC 02H .0502(a) & (b)J
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, structures (buildings, retaining walls, docks, impervious surfaces,
FORM:SSGP 10-2013 Page 1 of 3

etc.), 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: Gaston Nearest Town: Belmont
Subdivision name or site address (include phase/lot number):
Reflection Pointe Lot 247
Directions to site - please include road names and numbers, landmarks, etc.:
From 1-85 take HWY 273 south towards Belmont NC and proceed south until
Reflection Pointe Blvd intersection. Turn right onto Reflection Pointe Blvd and continue to
1533 on the left.
Latitude (in decimal degrees) 35.155615 Longitude (decimal degrees)-81.028485
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): New home built in 2013
6. Property size (acres): .65 Acres
7. Lake/ river/ocean adjacent to property: Lake Wylie
8. Describe proposed work (include discussion as to how ha�rd�X (KoU(�ti�e has been
avoided, or why it is necessary): Placement of s at the shorelin to protect
shoreline from further erosion. There is no shoreline stabilization currently at the location.
9. Will work be conducted from land? x❑ From water? EI
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal pool lake level/ Normal Water Level in square feet or acres:
200 sf
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water Level and 50 feet land-ward in
square feet or acres: 15Osf
12. 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): small shrubs
FORM:SSGP 10-2013 Page 2 of 3

Owner/Agent's Signature* [15A NCAC 02H .0502(f)l Date
Agent's signature is valid only if an authorization letter from the owner is provided.
Lake
(At Full Pond/Normal Water Level)
Full Pond/
Normal Water Level
Shoreline
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Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft)*:
1. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
3. Location of rip rap or fill to be placed below the Full Pond/Normal Water Level elevation
4. Location of any proposed structures such as buildings, retaining walls, docks, etc.
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corridors
FORM:SSGP 10-2013 Page 3 of 3

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