63111_Propose to construct a 5' x 72' pier with a 12' x 16' L-head platform_20180820

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GENERAL.;- . PERMIT, Previous -Oermit #
ew ElMoclikaboni. - O'do'rnp-le'te" Reissue 'ElPartial Reissue Date ptevious.per'Mit issued
As authorized by the Stafe'6 Environmental f North Carolina Department of E vironmental Quality
and the Cca' stal ResourcesComm , ssion4Wn n��rea of environmental concern pursuant to I SA NCAC
u,!es ched.,
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'Applicant Project Location: County )&r
Address 4�!20f' (Y
State
Phone #
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Authorized Age
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EjPTS_- Phone# G-1 Riven Basin`
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MEMO ONE
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XSee note on back regarding River Basin rules.
Agent or, Applicant PrintedNarri'v-
Signature **�rl_7te'7d compliance statementstatementon back of permit"
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Permit 0 ficer' rinted
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Issuing Date Expiration Date

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I. hereby certify that I own property adjacent
property located at S40
/�
(Address, Lot,
on d01, a r CO �ir%� , in
(Waterbody) .
! I
Df Prope Owner)
id, etc.)
L . N.C.
own and/or County)
The applicant has described to me,- as shown below, the development proposed at the -above
location: -
j- I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
_Pvl�v
WAIVER SE ION.
I understYnd that a pier, dock, mooring pilings, boat ramp, breakwater, at use, lift, or groin
must be set back a minimum distance of 15' from my area of riparian ac unless waived by
me. (If you wish to waive the setback, you must initial the appropriate blank below.)
do wish to waive.the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
Print or Type Name
Mailing Address
City/State2ip
Telephone Number/email address
Date
Information)
Signat e* "
ll/
Pr.; �y N FEE'.
Maifi Add ss r
City State/Zip rrC p
��
Telephone Nyrnb� / email address
Date*
(Revised Aug. 2094)
*Valid for one calendar year after signature*

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to FCC N- rVl 1 C E �� �' sC L
(Name of Property Owner)
property located at S- (o O JZJ5 S-r 14 0�Vr-nj e20 Ar ►�
(Address, Lot, Block, Roa4 etc.)
on EOM C I C O ' 121 V 6 e- , in g oLt 'o 2T CD N.C.
(Waterbody) (Cityfr wn and/or County)
The appli t has described to me, as shown below, the development proposed at the above
locatio .
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
il` Hall �.r ua�proposmi`+� evelopm must �tl/t1�ti%Scrl tidrlyb_ o>er or tt ch a site tl = i+vitt
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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.)
J-1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
W
malting Aoaress
W / Lrn
City/State&ip
Q/0 - l020 -7�`'�
Telephone Number/email address
Date
*Valid for one calendar year after signature*
r Information)
Print or Type Name
Mailing Address
7 '7g69
City/State&ip
.2r2 179 C,1 6755-7,
Telepho%j��e Nu�% ber/email address
8/12/1,
Date
(Revised Aug. 2014)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to _ (Z 09-Le 4 ►Vl 1 LE� �T �j;s� L
(Name of Property Owner)
property located at lwir-Ai - A20 A4 D
(Address, Lot, Block, Road,, etc.)
on __100M L ( C 0 921 V E -e- , in- AUJ46 iZT- CD N.C.
(Waterbody) _ (Cityfr wn andlor County)
The appli t has described to me, as shown below_, the development proposed at the above
locatio .
I have no objection to this proposal.
.I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
Q0A'T CI4e-^ T yJltC,1�`
t N -ro Z `
I SETirR�K ON : o
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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 16 from my area of riparian access unless waived by
m tf you wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
mailing Adaress
1LJ / L/!1 riJGT��i - n! L Z-g�j09
City/Stateaip
4/0- &20--7 /
Telephone Number/email address
Date
Information)
/,'-' 0-6 e� )e— :�s 9Z is k 7 m t P C
Print or Type Name
t fcf:;r �zv
Maili g Address
City/state/zi
z 5-2 4 -7
Telepho a Nu berlemail address
F�`2��
Date's -�
"Valid for one calendar year after signature* (Revised Aug. 2014)

NC DDivision/ of Coastal Mgt.
Applicant:(
Date:
General Permit #:�l
Habitat Impact Computer Sheet
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 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)
Dredge ❑ Fill ❑ Both ❑ Other
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Dredge ❑ Fill ❑ Both ❑ OtherA
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.nccoastaimanaaement.net revised:02/03/10