20170035 Ver 1_Shoreline Stabilization_20170106

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Provide three (3) copies of the application and supporting information (maps, drawings, etc.),
as well as the appropriate application fee (see below), to the Division of Water Resources,
401 & Buffer Permitting Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617.
I. Zpy�nInformation
Owner Information: Please provide complete and accurate contact information
Agent Information: Per 15A NCAC 02H .0502 , an agent may be given signatory
authority for the owner/applicant if a signed and dated copy of an Agent Authorization
letter is included with the application. (A sample form may be found at
http://www.saw.usace.army.mil/Portals/59/docs/regulatory/regdocs/Permits/SAMPLE
AGENT AUTHORIZATION FORM.pdf)
II. Proj Information
Vicinity/ Site Map: Some type of site map so that someone unfamiliar with the area can
locate your project. A county map or USGS topographic map indicating the project
location is usually sufficient.
Pite Plan: A site plan showing the location of the shoreline, location of the impacts to
the shoreline and/or lake bottom and the location and any vegetated areas that will be
impacted. In most cases the site plans do not have to be professionally prepared.
However, if you intend to conduct hydraulic dredging, professionally prepared drawings
I likely be required for the spoil structures. See example below.
5JZ P otograph of shoreline to be impacted/ disturbed
Description of property (including location information and lat/long coordinates) and
isting features on and near the site
eDescription of project and impacts/ disturbance proposed
Ill. Sig ture
Per 15A NCAC 02H .0502 , the application shall be considered a "valid application" only
if it bears the signature of a responsible officer of the company, municipal official,
partner or owner. This signature certifies that the applicant has title to the property, has
been authorized by the owner to apply for certification or is a public entity and has the
power of eminent domain.
IV. ±p0itation Fee
The application must be accompanied by the appropriate application fee (checks made
out to the NC Division of Water Resources). The application fee is as follows (pursuant
to15.3D):
40.00 f r impacts to lake (below normal water level) of less than 1 acre
➢ $ .00 for impacts to lake (below normal water level) of greater or equal to 1 acre
INSTRUCTIONS FOR APPLICATION SSGP307980 08-13 & SUPPORTING DOCUMENTATION Page 2 of 3

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DWR State of North rolina /
Department of Environment and Natural Resources
Division of Water Resources
Division of Water Resources
1SA NCAC 02H .0500 — Water Quality Certification
Instructions for Application FORM SSGP 10-2013
(Shoreline Stabilization 401 WQC to accompany USACE GP30, GP79, or GP80)
Instructions for Shoreline Stabilization Application
When to use this form — This application form should be used to apply for a 401 Water Quality
Certification to impact:
When this form should not be used — This application form cannot be used for wetland or
stream impacts. This information does not apply to landowners within the twenty coastal
counties that are affected by Division of Coastal Management (CAMA) rules.
For more information — If you have been advised that you require a 401 Water Quality
Certification, and would like more information about:
r The application process: http://porta1.ncdenr.org/web/wq/swp/ws/401/certsandpermits
How to download an application form:
http://porta1.ncdenr.org/web/wq/swp/ws/401/certsandpermits/apply/forms
y Application fees:
http://Porta1.ncdenr.org/web/wq/swp/ws/401/certsandpermits/apply/fees
If you are unable to download this information or application, please call [phone] to
request an application with instructions.
Please note — Not all impacts require written authorization from DWR. This may include the
construction of docks or boathouses if there is no dredging or filling involved (other than the
pilings). For more information, please visit the following website:
http://Porta1.ncdenr.org/web/wq/swp/ws/401/certsandpermits/fags#always have to apply
How to apply — When submitting an application to DWR, please use the following instructions
as a checklist in order to ensure all required items are submitted. Adherence to these
instructions will help facilitate a quicker review time and reduce the amount of requested
additional information. D
INSTRUCTIONS FOR APPLICATION SSGP307980 08-13 & SUPPORTING DOCUMENTATION I Ilag6W4 30 6 2017
U.S. Army Corps of
Description
Engineers (USACE) Permit
Federal Energy Regulatory Commission (FERC) regulated lake
shore or bottom
GP30
Tennessee Valley Authority (TVA) regulated lake shore or bottom
GP30
Local government regulated lake shore or bottom
GP30
USACE Reservoir owned/regulated lake shore or bottom
GP79
Private lake shore or bottom
GP80
When this form should not be used — This application form cannot be used for wetland or
stream impacts. This information does not apply to landowners within the twenty coastal
counties that are affected by Division of Coastal Management (CAMA) rules.
For more information — If you have been advised that you require a 401 Water Quality
Certification, and would like more information about:
r The application process: http://porta1.ncdenr.org/web/wq/swp/ws/401/certsandpermits
How to download an application form:
http://porta1.ncdenr.org/web/wq/swp/ws/401/certsandpermits/apply/forms
y Application fees:
http://Porta1.ncdenr.org/web/wq/swp/ws/401/certsandpermits/apply/fees
If you are unable to download this information or application, please call [phone] to
request an application with instructions.
Please note — Not all impacts require written authorization from DWR. This may include the
construction of docks or boathouses if there is no dredging or filling involved (other than the
pilings). For more information, please visit the following website:
http://Porta1.ncdenr.org/web/wq/swp/ws/401/certsandpermits/fags#always have to apply
How to apply — When submitting an application to DWR, please use the following instructions
as a checklist in order to ensure all required items are submitted. Adherence to these
instructions will help facilitate a quicker review time and reduce the amount of requested
additional information. D
INSTRUCTIONS FOR APPLICATION SSGP307980 08-13 & SUPPORTING DOCUMENTATION I Ilag6W4 30 6 2017

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v170035
State of North Carolina
Department of Environment and Natural Resources
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
Four copies of the appflication (including attachments) and the application fee should be sent to:
Division of Water Resources
401 &Buffer Permitting Unit � � j�
1617 Mail Service Center
Raleigh, NC 27699-1617 li .)/SIV 0 a ZOi�
I. Applicant Information [.:1:5A NCAC 02H _0502(a)]
1. Owner Information
Name: WILLIAM R. DICKERSON
Mailing Address: 4325 BLOSSOM HILL COURT
RALEIGH, NC 27613
Telephone Number: [phone] [phone] Fax Number:
E-mail Address: [e-mail]
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http:jlwww saw iaSacE' �ii�i�y.r7�il!Pc�rYz�is% 9jci�c�/rc�alr�t4�ry�rr��?rio�/PergYi't�sSn �F'1_E NCEf•Ir i�,UTN
©RIZATION FORM.ndf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Person to receive the Certification Approval: OWNER
If. Project Information [,U SA.iN 'AC 02H 0.502(a)
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 4

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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.) EXISTING SEA WALL IN PLACE.
4. Location of the property (where work is to be conducted)
County: FRANKLIN Nearest Town: BUNN
Subdivision name or site address (include phase/lot number): LAKE ROYALE, 947
SAGAMORE DRIVE, LOT 1704
Directions to site - please include road names and numbers, landmarks, etc.: FROM LAKE
ROYALE SECURITY GATE, STAY RIGHT ON SHAWNEE, TURN RIGHT ON TO SAGAMORE. 947
WILL BE ON YOUR LEFT.
5. Describe the existing land use or condition of the site at the time of this application
(residential, undeveloped, etc.): RESIDENTIAL
6. Property size (acres): 0.44 ACRES
7. Lake/ river/ ocean adjacent to property: LAKE ROYALE
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): BOAT SLIP AND COVER
9. Will work be conducted from land? 0 From water? 0
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:
PIERS AND FRAMING FOR THE SLIP WILL BE PLACED LAKESIDE (10 FT X 12 FT). BOAT SLIP
WILL PROJECT 10 FT FROM EXISTING SEAWALL INTO LAKE AND WILL BE 12 FT WIDE WITH
4FT DECKING ALONG BOTH SIDES
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: 360 SQUARE FEET (10 FT X 12 FT X 3 FT) EXCAVATED TO FORM HALF
OF BOAT SLIP. 4 FT DECKING AROUND THE SIDES AND BACK.
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): 1 PINE TREE AND
POSSIBLY 2 SMALLER TREES.
Owner/Agent's Signature* [15A NCAC 02H .0502(f)j Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

L'01 170
,piLUuhcP SIY�
Full Pond/
Normal Water Level
1 (� Shoreline
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�-' 2 —ii
C 10
_'11–N
La ke
(At Full Pond/ Normal Water Level)
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.
S. 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

NAP. '26_99 TF4ti 29:4r HM RUBERT U. WXILI{F`�M�rS (`RLS.S 1 949 269 5734
NOtE: Si1NG LOT 1704 OF LAKE ROYALE FORMERLY BoomKE 12. PGpb�.
MAP 8 OF 4.0. SHEET 3 OF I. RECOItDE
L E ROYAI.F. 16' BOAT DOCK
EDGE OF WAY R Ae,' EXTENDS 9.5' OFYONO
N 144 - E 97.62 PROPERTY LINE
Of 170 I
ADDRESS: ITo4 SAGAMORE DR.
SUNK. H.G. 0.44 AC.
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LOT 1703
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0 EXISTING IRON
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L07 1705
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i_ 40.00 - ! POWER LINE
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fQ•N� �` A9 SUiLT A _'� ND
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40 20 0 40 BD
R/W
HOUSE.' 40CAT ION FOR
;`t,.�l•.r t:,' ; . y,�o' ;e;'�,�'.�;' y MAR IAM CATAPANO
CYPRESS CREEK TOWNSHIP
{ l_IliT '� � �'�• % FRANKLIN COUNTY
/`�` ""'�:.:••'�, SEAL NORTH CAROLINA
•..sE�►
1, ROBERT G. WILLIAMS, carllfy that under my 401101on and ROBERT G. WILLIAMSLANDS
supervision this map was drawn from an actual field surrey; Ihof REGISTERED LAND SURVEYOR
the error of ci$suro of the survey ds caloulated by latitudes and
ZEBULON, NORTH CAROLINA
1 departure$ is 1: 10000 • that this map was prepared In Taleph"41 289-!700.
oeeor/oncs with B.br. 47-30 as amended.
DRAWN BY:
witness my hdh4(14 an s 1h1 /20 day of MARCH, 1999.
ROW i EL1r
L•141T 40, 424"r�ari CHECKED BY: RGW
Sworn to and subscribed before me thl 23 day of N� CH; 1998.
DATE: 3-25-98
Mr' Cemmissi0n eKpirea: 3'17' 00Y SCALE: 1"F40'
NOTARY PUB IC Field Book: 62

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Michael T. Langley 3192 Lewis Road
NC License #31693 Elm City, NC 27822 �C'.'-- ..............r
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