71287A_Betty Gard_20190103

)�CAMA / 'DREDGE & FILL NO 71287
GENERAL PERMIT Previous permit # CX) B C D
4New -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 I SA NCAC C)
R les attached
Applicant Name
Address j G`GO S�v�U t� 5 ift,}- l iK
City Eli�llr%'Al StateAL-e—ZIP 277-_5Z
Phone # (252) E-Mail
Authorized Agent i Z
Affected ❑ CW YEW )')PTA �#S ❑ PITS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
ORW: yes /(KO? PNA yes /('90
Project Location: County,14ZL '_'j&I
Street Address/ State Road/ Lot #(s)
I 'LZ(i `�CalVI> s 1 tne!.r- %ilk v
Subdivision U .f
City ge'1' / ZIP
Phone # (252 ) Z- River Basin TO�d�C
Adj. Wtr. Body LU Egli !/ CL -- efig/man /unkn)
Closest Maj. Wtr. Body 5'KG!iyi
Type of Project/ Activity 1'r� ;'144u111)
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Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
Applic ionFee(s) t Check#
L AYA77YI f
Permit Officer's Printed Name
Signatt I
—lulu • �� 7v/q
Issuing Date Expi tion Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to h L�7-!'1/ U/, �f�KO 's
I (14ame of Property Owner)
property located at /-)R.
r(Address, Lot, Block Roa , etc.)
on 141- gzrAlXf 5 &L1. ✓1i , in , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatio .
1 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 attach a site drawing)
R PJ-A C F &-�X1,57-ml g(/LK#,�-cXp
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.)
�-- I do wish to waive the 15' setback requirement.
i
I do not wish to waive the 15' setback requirement.
(Pr perty O er formation)
Signatu e
rint or Type Name
Vzas Sad P S #vkAgf��O?,
Mailing Address
eS.�71/TVW , AJ6 27?-32
City/Sta ip 92
Telephone Ndmber/email address
Date
(Adjacent Property Owner Information)
Print or Type/Nam
iai� so��r�.s'6/ae�,nR.
Mailing Address
EP252V oAl , ,t/C
ar�5.�>400,7- y366�
Telephone Number/email address
Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature*

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ' E 's
ame of Property Owner)
property located at
(Address, Lot, block, Road, etc.)
on 14.48t7llAq1.j,5' sOtlNF in SOW-MAl N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatiory
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 attach a site drawing)
i �
R�G PA GF
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.)
✓ I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Pro erty Ow er Inf rmation)
;0�
Signatur
Print or Type Name
/Z; o -YM1,A0
Mailing Address
City/State/Zip
Teleph ne Number /em it address
Date
nt Prope OwnerInformation)
/
G f1
E2�ANK MlG-4/MR.i
Print o Type Name
i .�Z ZZ Sd41,�O ds�l9C bR
Mailing Address
E2�eiVI'a�✓, nlc 27432
City/State2
//97
Telephone N mbe /email address
-2/2gf/JP
Date
'Valid for one calendar year after signature"
(Revised Aug. 2014)

RdDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor Names H. Gregson, Director Dee Freeman. Secretary
AGENT A!JTHORIZATION FORMI~OR PERMIT APPLICATIONS
Date,
Name of Property owner Applying for Permit
Mailing address:
AA5- a7
I certify that I have authorized LY-- (agenticontractor),
to act on my behalf, for the purpose"of applying and obtaining all CAMA permits
7 � necessary for the proposed development of Z
Z
at my property located at, / '4.�
r
11�7 (date).
0A
1367 U.S, 17 South, Elizabeth City, North Carolina 27909
Phone: [phone] N FAX: [phone] \ intemet: wwrliccoastalmanagernent-net
An Equal Opportunity t Affirmative Action Employer- 50% Recycled � 10% Post consumer Paper

NC Division of Coastal Mgt. habitat Impact Computer Sheet
Applicant: Permit #: 7/ Z6 7 4
Date: (/
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
ternimpacts)
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
tem impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
S E-Ltot/t
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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 :: w-.vw.nccoastaImanarge-ment.net revised: 02,' 3110

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