20190494 Ver 1_Shoreline Stabilization_20190416

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
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources Oft
401 & Buffer Permitting Unit (� FA
1617 Mail Service Center
Raleigh, NC 27699-1617
2090494
I. Applicant Information [15A NCAC 02H .0502(a)]
1. Owner Information
Name: Scott & Chiho Haley
Mailing Address: 3620 Dockside Lane
Sherrills Ford, NC 28673
Telephone Number: 704/965-1060 Fax Number:
E-mail Address:
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: Beth Mosteller
Company Affiliation: Dale & Beth Lake Use Permit Service
Mailing Address: 988 Clear Creek Circle
Lincolnton, NC 28092
Telephone Number: 704-996-3245 Fax Number:
E-mail Address: [e-mail]
Person to receive the Certification Approval: Beth Mosteller
II. Project Information [15A NCAC 02H .0502(a) & (b)]
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: Catawba Nearest Town: Sherrills Ford
Subdivision name or site address (include phase/lot number): Lot 10
Directions to site - please include road names and numbers, landmarks, etc.:
see attached
Latitude (in decimal degrees) 35.59276 Longitude (decimal degrees) -81.006596
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): .58
7. Lake/ river/ ocean adjacent to property: Lake Norman
8. Describe proposed work (include discussion as to how hardening of shoreline has been
avoided, or why it is necessary): Due to heavy wave action, bank is falling into lake — 3
trees aoaroximately 5' from lake need to be removed to slope shoreline for stone.
9. Will work be conducted from land? ® From water?
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:
115.8' along shoreline
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: 115.80' along shoreline will be rip -rapped. Access for small
skid steer along oroiect
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): grass -fescue
kn,. , Beth Mosteller
Owner/Agent's Signature* Printed Name Date
FORM: SSGP 10-2013 Page 2 of 3

[15A NCAC 02H .0502(f)]
`Agent's signature is valid only if an authorization letter from the owner is provided.
Full Pond/
Normal Water Level
Shoreline
La ke
(At Full Pond/ Normal Water Level)
Rip -Rap will be placed: 115.8' to
follow contour of shoreline,
one foot above full pond,
and 3-4 feet below full pond
Scott & Chiho Holey
3620 Dockside Lane
Sherrills Ford, NC 28673
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

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 10 PLAN NO. PARCEL ID: _ 460701366740
STREET ADDRESS: 3620 Dockside Lane, Sherrills Ford, 28673
Please print:
Property Owner: Scott Haley
Property Owner: Chiho Haley
The undersigned, registered property owners of the above noted property, do hereby authorize
Beth Mosteller , of Dale & Beth's Lake Use Permit Service
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
same as above
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Aw--�
Authoriz nature
Authorized Signature
Date: Date:

CATAWBA RIPARIAN BUFFER NOTIFICATION FORM
Project Name/address: 3620 Dockside Lane, Sherrills Ford, NC 28673 County: Catawba
Owner:
Print
Contractor/agent: _
re
Print Signature
The approval is for the purpose and design described in your application. Impacts not indicated in the
application is a violation of the Buffer Rule. Site specific work should be provided in the application. [15A NCAC
02H .0506 and 15A NCAC 02B.0243(8)]
Trees are not allowed to be removed from Zone 1 of the Buffer (within 30 ft of the full pond elevation), unless
approved. Exception, those trees that are severely undermined along the immediate shoreline can be removed.
Minimal shaping and sloping along the immediate shoreline is allowed. [15A NCAC 02B.0243(6)]
Benching, grading in the buffer is not allowed. Excessive disturbance of ground cover. [15A NCAC 02B.0243 (6)]
Beaches, impervious patios, impervious walkways, etc. are not allowed in the buffer unless specifically approved
by the Division. There are limitation on size for decks. [15A NCAC 02B.0243(4) and (6)]
Work to be conducted from land must indicate an access and indicate any trees that are to be removed. The
work corridor should be described. The approved access corridor shall be restored. Staging, spoil, construction
material must be outside the buffer. [15A NCAC 02H .0502 and 15A NCAC 026.0243 (4), (6), (8)]
Stormwater cannot be piped or channeled for direct discharge to the lake. All constructed stormwater
discharges must be at the natural elevation and discharged prior to entering the buffer directed as diffuse or
sheet flow at non-erosive velocities to the lake. [15A NCAC 02B.0243(5), (6)]
Acknowledgement of Notification
I, Scott & Chiho Haley , hereby state that I have been informed of the Catawba Riparian
Buffer Rule. Any work conducted in the buffer, not specifically stated in the application and approved by the
Division of Water Resources (DWR), is a violation and subject to enforcement. Due diligence will be taken such
that the construction will be built within substantial compliance and intent of the 401 Water Quality
Certification and Buffer Rules, the approved plan(s) and specification(s), and other supporting materials.
Signature (owner): Date: f t Ar ZL

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