72510A_Robert Booth_20190102

CAMA /aEDGE & FILL No. 72510GEEPERMIT Previous permit# B C D
xNew ❑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
Rules attached.
Applicant Name R u h* r 1 Qvo t Project Location: Countyr . 1 vC It
Address 1 Li1 1 ac V,` L ry— i PO 111 ati) Street Address/ State Road/ Lot #(s) I i1\: f.)u IS l� u
CityPo . n i 1�o,'hv r Stated ZIP a I5 to t l
Phone # wu-'S i"} S E-Mail
Authorized Agent
❑ CW
❑ EW ❑ PTA X ES ❑ PTS
Affected
AEC(s):
❑ OEA
❑ HHF ❑ IH ❑ UBA ❑ N/A
1-1 PWS:
ORW:
yes / ��
PNA yes / CT1O
Subdivision ----
City Poo ,, t Nor bvt ZIP a-Iq(ny
Phone # ( ) River Basin
Adj. Wtr. Body �uc JL S+v e\cA r'W /man /unkn)
Closest Maj. Wtr. Body
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11111 NOMEN Hills
10, %22 3350,01nallral
Agent or pl' Printed Name /►
G�l-
Signature ** Please read compliance statement on back of permit
A aov. Uv 3�;I1
Application Fee(s) Check #
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Permit
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Dat
Issuing e Expiration Date

NC Division of Coastal Mgt. Habitat impact Computer Sheet
Applicant:�OD�
Date: t /�—// cr
Permit #: 7-1510 A -
Describe beld'W 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)amount
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
Dredge ❑ Fill ❑ Both ❑ Other
4` v
< co U
. c9
Dredge ❑ Fill ❑ Both ❑ Other ❑
C) O
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
I
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 n www.nccoastalmanagement.net revised: 02/03/10

Address of Property
Agent's Name #:
Agent's phone #:
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERED
Name of Property Owner: f //�
1 j.J 0 A 14 & -ri -t 10U 1 h I l�jgY r ✓l
(Lot or Street #, Street or Road, City & County)
c 1� FJ c)4+
Mailing Address:
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawinai with dimensions,- must be ar©Ade .-with his meter.
I have no objections to this proposal. I have objections to this proposal.
if you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Correspondence should be mailed to 401 S.
Griffin St., Ste 300, Elizabeth City, NC, 27909. DCM representatives can also be contacted at (252) 264-
3901. No response is considered the same as no objection if you have been notified by Certified Mail.
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 sign the appropriate blank below.)
(Pro erty Owner Information)
Signature
Ko
Print or Type Name
,Mailing Address
City/State2ip
Telephone Number/Email Address
Date
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Adjacent Prop�wner Information)
-�. �i
Signature *
�b �j Lw' ( te vrr V1
Print or Type Name
(b kq (, 6v4" Po -Ad
Mailing Address
City/State/Zip
q (� -9 -7
Telephone Number / Email Address
/1/DV
Date*
*Valid for one calendar year after signature`
Revised 2017

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERED
Name of Property Owner:
e r f C_ -[�;C o if4 1, -Tt4i,1
Address of Property: / ��'`�� C- ✓171 e ?14 // ..- /I C !;c7 l&
(Lot or Street #, Street or Road, City & County)
Agent's Name #:
Agent's phone #:
Mailing Address:
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing with dimensions must be provided with this fetter.
I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Correspondence should be mailed to 401 S.
Griffin St., Ste 300, Elizabeth City, NC, 27909. DCM representatives can also be contacted at (252) 264-
3901. No response is considered the same as no objection if you have been notified by Certified Mail.
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 sign the appropriate blank below.)
(Pr erty Owner Information)
C_
Signature
go hL, r7rr
Print or Type Name
Mailing Address
A,/C
City/State/Zip
Telephone Number / Email Address
Date
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Adj , nt Pro per
wber Infor tion)
7
St ature
i (Aa 6 I
Print or Type Name
( o(--
Mailina Address
City/State/Zip
Telephone Number / Email Address
II-3-1�
Date*
*Valid for one calendar year after signature`` Revised 2017

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