72197_Extend L-head_20180801

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N2 , i 2197 A Cv D`r
GENERAL PERMIT J
:
Previous permit# 1,J A.
NNew ` -' OModifcation OCoO mplete Reissue Partial Reissue Date previous permit issued iy ),4
As authorized by the State of North Carolina,. Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC.
'
- 19� Rules attached.
' •Applicant Name"�=srlic��C J-� ��A •
Project Location: Countyc
Address 376
Street Address/ State Road/ Lot #(s) �( `S -'i L y>,
City ►awl) r s li? State �A c ZIP —Z--)Q a t}-
Ca ram, t_ t-) d c� 13.z)Aq--g
` Phone # E-Mail "`
Subdivisions
Authorized Agent W1A -y— t,6, -si
City ZIP -`Z-1
❑CW DEW • PTA DES /4PTS ,
Affected
Phone # ( ) River Basin—,
❑ OEA O HHF ❑ IH- 0 UBA ❑ N/A
AEC(s):
Adj. Wtr. Body ,, a /mom)
.O PWS:
ORW: yes /.,ono PNA ' • yes / no
Closest Maj. Wtr. Body�A M u r
=•. Agent or Applican Pri t d Na e
'- Signat re Hl iaseread'compliannccee'statementonback ofpermit
Application Fee(s), Check #
,Permit-O ficer's Printed Name - ,
CLSignat re
Issuing Date Expiration Date -

J-�,s r> OV

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
i hereby certify that I own 'property adjacent to
(Name of'Property Owner)
property located at l3 ekllf � fa � '` 1
(Address, Lot, Block, Road, etc.)
on b f ae(P'A - 4f _ek , in B %Gv's" N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatio .
A4 I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT_
WAIVER SECTION
I understand that a ,pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set back a minimum distance of 15' -from my area of riparian access unless waived by
me. (if you wish to waive the setback, you must, initial the appropriate blank below.)
1 do wish to waive the 15' setback requirement t er �h
I do not wish to waive"the 15' setback requirement.
(Property Owner I
a�c�rccccur c L- 'b
11f/I fir
Print or Type Name `{
�� �r1lc� Ur
MailingJJA,ddress/
A 4h"1
City/Stator p
Telephone Number/email/.address
-Z_5'z- 5,71 3381
(Adjacent Property- Owner Information)
Signature*/
Print or Tyye Name
Mailing Address
CrtylState0e
Telephone Number/ email addrag_
-7 _<Z-.� 7J-�l t
Date Date*

ADJACENT RIPARIANPROPERTY OWNER
STATEMENT FOR'CAMA MINOR PERMITS
I hereby certify that I own property adjacent to
P 7e r- h o/y
(Name of Property Owner)
property located at { 1
Address, Lot, Block, Road, etc.)
on /614/1 IS C �` e2Gc in 8 e4 'k r-1 N.C.
(Waterbody) (Town and/or County)
He has described to me as shown in the attached application and project drawing(s), the development
he is proposing at that location, and, 1_ have no objections to his proposal.
(APPLICATION AND DRAWING OF PROPOSED DEVELOPMENT ATTACHED)
20!4 A?�
Signature
Ol/f f �t %' C &uc.
Print or Type Name
Telephone Number
Date

ADJACENT RIPARIAN PROPERTY OWNER
STATEMENT FOR CAMA MINOR PERMITS
I hereby certify that I own property adjacent to s
(Name of Property Owner)
property located at 7`J — '7/7Z �%Cs1 Le c11e1� A^ttle, ,6c7c � een ,
Address, Lot, Block, Road, etc.)
on131e,G.-lS 4f1J �eEc in 1��4 c*�` N.C.
(Waterbody) (Town and/or County)
He has described to me as shown in the attached application and project drawing(s), the development
he is proposing at that location, and, I have no objections to his proposal.
(APPLICATION AND DRAWING OF PROPOSED DEVELOPMENT ATTACHED)
Signature
/D' /- C
Print or Type Name
Telephone Number
Date

Applicant: r�.1,." n i . o '
Date: l A K ti" s T Za t�
General Permit
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Mame
DISTURB TYPE
Choose One
TOTAL Sq. Ft
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
O P c'Z�l
y�q.�yl
Dredge ❑ Fill ❑ Both ❑ Other �
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r-t.
Ztic7 f>zr
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ . Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑