72750D - Haizlip

.............
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North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Michael F. Easley, Governor James H. Gregson, Director William G. Ross Jr., Secretary
Authorized Agent Consent Agreement
-pio-c r is hereby authorized to act on my behalf
(Panted Name offont)
in order to obtain any CAMA permit(s) re1luired for the property listed below. The authorization is limited to the
specific activities described in the attached sketch.
LOCATION OF PROJECT:
PROPERTY OWNER MAILING ADDRESS:
PHONENO.
AUTHORIZED AGENT MAILING ADDRESS:
Amer'is ranffin-rin e- C- na l
C,
PHONE NO. Li S -I !SA 'Do
Signature of Property Owner:
Signature of Authorized Agen
Da
127 Cardinal Drive EA, Mmington, North Carolina 28405-3845
Phone: [phone] FAX: [phone], Internet: www.nccoastalmanagement.net
An Equal Opportunity 1 AffrmaWe Action Empbyer- 50% RecycW 110% Post Consumer Paper

Name of Individual Applying For Permit: l7 env 4__Icy zi 1
A ddmss of Property —1 �3 cl �'�► �� � ��"c�tc.i1
(tot or Street A. Street or Raid)
.Ciry and Co"tyi
hereby certify that I own property ardjaeet t to the above -referenced propet^.y. The individual
appiying for this permit etas described to me as shown on the anschtd dmwu:g the deveiopnyestttt"
are proposing. A desolation or drawing, with dimensions, should to crpvide_+ with this k ier
11 have no objections to this proposa:
If you have objections to what is being proposed, please write the D«i,it.,n of C96$*L
Management, 127 Cardinal Dave Extension, Wilmington, NC 28405 or call 910?96.71 jS
witbin 10 days of receipt of thli notim No response is considered the some as no 0006M on if
you have been norilied by Certified Mail.
WANER SECTION
l understand rhat a pier, dock, tttvorlag pilings, breakwater, bout :louse or boat (ift anvAbeset
hck a minimum distance of is, from my area of riparian access -unless w2i. ed b_. ime, UfYeu
wish to waive the setback, you must initial the appropriate blank below ;
do wise to waive the 13' setback rtauirer,e--
i A2 nZ wish to waive the I S' setback
�'BTtnIC :ate
Print Name
-moo C: , C�% ri � NCDENR
Telephone Number with Arcs Cock

Name of Individual Applying For Psttait:AFL Z-1i P
adM of Propetty
`tot or
or RoW
Sok PC), � (-�C 2 L,
iCiry bl(d:otfl3tyl
hereby certify that i own prop" adjsoant to the above -references proPCM... The trtdivi*w
applying fOt this permit has described t4 rotas Shown as the wed drawiag the devtkprnM #w,
are proposing. A descriotisn cr drowing, with dimeaalons. should be crovi¢ed wish this lamer
have no objeoaons to tnis proMosa;
:I' }ou have abjetiiorts to whet :s being proposed, pisass write the Dt•iY,%rti of C*6pM-
Management, 121 Chrdla4 Drive Fa smioa, Wilmington, NC :8445 or ::111 a1??96.71t5 witbin 10 days of receipt otthis Antics. No response is considered the so me as no Obilemion if
you have been notified by Certifled Mail
W AMR SECTION
u8derSMQd rant a pier, dock, =grin# pilings, breakwater, Oaor :louse or boot iift O"Stbeset
bcka minimum distance of it, from my area of riparian access - unless waived b% nk. of tosu
►ri to Naive Ole setback, you must initial the egpropriate biunk below
do wish to waive the i 3' se:heck reocire—-.
i gR nRt a Ish M waive the 1 t' W60Ci;
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Print Name
34
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Data Received
Date Deposited Check From Name
Name of Permit Holder
Vendor
Check Number
Check
amount
Permit Numb —Comments
Recai t or Refund/Raalbcafed
Columnf
Column2 Column3
ColumM
Column5
Co1umn6
Column?
Column6
Column9
19' Amer— Mari
we H-ft
1 888 8
QP 07 780