71229A_Island Haven, Inc._20180927

%CAMA / LYDREDGE & FILL N2 / 1229 & B C D
GENERAL PERMIT Previous permit#
7New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
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 15A NCAC li . I (UU
Rules attached.
Applicant Name I-) c ,cy Haut 1 r c Project Location: County .4�J c K
Address Cu 1,, ox i Uo Street Address/ State Road/ Lot #(s) q J L,,L ,, I1y ICc►
City C.a r r c IL State Ld _ZIP a ids+
Phone # (25,A) 10 -4 -W uS > E-Mail
Sri it I I,, L
Subdivision
Authorized Agent \0%J a
13u < <
City �' o r '� o c. K
ZIP ] 1 c+.\5
ElCW [WEW
1p PTA PIES ❑ PTS
Phone # ( )
River Basin Pc } c .' k
Affected
❑ OEA ❑ HHF
AEC(s):
❑ IH ❑ USA ❑ N/A
t
Adj. Wtr. Body Cie r 7v k
f%.-cl is man /unkn)
❑ PWS:
Closest Maj. Wtr. Body
ORW: yes /� PNA
yes
Type of Project/ Activity
t i SZ g j G ue i?
"A
(Scale: : 30' )
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length Ilyp '
avg distance offshore a
max distance offshore_
Basin, channel
cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bul
Other
Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of permit **
Application Fee(s) Check #
WE
❑ See note on back regarding River Basin rules.
'--Z c- I d
Permit Officer's P '
si
J�0IT
Issuing Date Expiration Date

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: TSB,Permit #:
Date:
Describe belo'�t the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Name
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)
5
Dredge ❑ Fill Both ❑ Other ❑
' �O
3 d, o
6% 01, -IIA.L
Dredge ❑ Fill [X Both ❑ Other ❑
(p U
t + v
f
Dredge ElFill ElBoth ElOther
�o O
�j d-0007
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 ❑
252-808-2808 :: 1-888-4RCOAST :: www.nccoestaimanagement.net revised:02/03/10

AGENT" AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: 'I 5 ( c/vJ NmAle y-1 ► ri (,
Mailing Address: W-kCf i� Ro) C©A)cc l�G
Phone Number:'��- )_ 01�
Email Address:
I certify that I have authorized %_A)°''y'^'(- f� )f C/"-
Agent / Contractor
:o act on my behalf`, for the purpose of applying for and obtaining all CAMA permits
necessary for the fcollowing proposed development: l% ,I d u O of
1.-., 6,_ / D /
at my property locEited at 6W !] L-A-y---lam' 1 l
in ���f/,�J��— County.
1 furthermore certify that l am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Properly Owner Information;
Si,7pature
Print or Type Name
Title
Date
This certification is; valid through ! )— /, I / l f,

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
tb
T-S 1 el —)
it it� calk thik ill Ox" pmpeft agjff� Y—le-v" -Tye-
'pmw ltw�,;#.
-e-r I,
ddress, Lot, Block. Road, etc.)
L) V
7 lit P *e apojiwt has - pg r e � evetopme ipposed at the above
tka) me, as; st�� breibs',I Jh a
'toff
I have nb objecitiontD INS PrOPOSal
-:" , - - --- in "' 1 Flu, . 11 0 Iii I ill Miam
Rmwvl=ANMA)RDRAWANSCIF i�!ROPOSEDDEVELDPMENT
IF OPH" S&INIMI fmmost 40 ra dles=*fian beiew zor Aftch a site drawing)
0 1 6 0 / 0 0 1 1 4- 0 of f'N 6.1
i B o I �- L,
1d. 11
4L-,-- 5,') e-
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp.. breakwater, hoMfimiw, lifft, =906ir
imumd he sed tint* a inn, i nii mi, u mi, disdariweof 15' UMM" M,..Y zxez- ef �Apamanzamw U "*W WoweW tty�
I ff shtkm *a seftz*, Ww want kMM lhe�Wprop6i
game - -ift ialarik be{ow.}
.711 ft vww�-ft zfaii�ve me is, SdftS& M*&SURIft.
11 ft mwd\wa& tb cow& ae'lissefte& ffaquireffierit.
j&"Mft &New &'farm"Qw
Print or -Type Wame
Telephone Number/email address
l(AdjacwA . P �
OWWWr hdoffflatm)
Z
PnI10 T 'N
ez
Telephone Number/ email address
W61'idlor one calendar year .1ftersigmMuTT
PaDywd&V. 2014

r
ADJACENT RfFARfAff F3R0PEfc T i't`3'00'VER STATEAfQNT
I hereby certify that I own property adjacent to -� S /---V4 r1rV- ` ,,- 1 s
romp-n# Prnpertty Owner),
property located at -6 L'' r ' IV r `-G`
t Address, Lot, Block, Road, etc.)
0) C J I'P �✓' 221. s0, in t'
(Waterbody) (City/Town ands°or County)
N.C.
Thp applicant has described to me, as shown below. the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attfrh. a site drawing
04
ov, N©r S ".1 �e-
WAIVER SECTION
I understand that a pier, dock. mooring pilings. boat ramp.. breakwater, boathorase, lift, or groin
,m. kset .be e.f .back a minimum distance of 15' from my area of riparian access unless waived by
me. (If711
ish to waive the setback. you must initial the appropriate blank beiow.j
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
Owner Information)
.its ltlli'(' � J
Print or Type Name
it Me-
iul /Zip, IC N
Telephone Number/ mail address
address
17utc
(Adjacent Property DNgrwr.tnfarmatioR)
�1;,'lltllll7'(''
Print or Type Name
Mailing Address
City/StatelZip
Telephone Number/ email address
'Valid for one calendar year after signature'
(Revised Aug. 2014)

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