69197D - Cooper

,y
LAMA / DREDGE & FILL 1
.GENERAL PERMIT Previous permit#
)Oew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources 0,140and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC 02
Applicant Name I O i a 00 t,.✓ -�
Address 2
City �jq 'j/�( J, State
�VL ZIP zU
Phone # ) 7M— 1 E-Mail
Authorized Agent JO 1' ^
Affected ❑ CWTA El ES ❑ PTS
AEC(s): ElOEA "ElHHF /❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes / /') PNA yes / no
Type of Project/ Activity
a V�� I in C— L c`T—� I LOCIL H 4,
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length
avg distance offshc
max distance offsH
Basin, channel
cubic yard/
Boat ramp
Boathouse/ atli I D
Beach Bulldozing
Other
❑ Rules attached./
� Project Location: County pol ,t,n C'C...
Street Address/ State Road/ Lot #(s)
Subdivision
City (14? A 'k (ir ZIP G
j `1
kon� # (�jd) �L7"�� S� River Basin L VVA
Adj. Wtr. Body �(,L ✓l G% (nat /�)
Closest Maj. Wtr. Body A1 (A-1 IA
Shoreline Length 0 O
SAV: not sure yes o
Moratorium: n/a yes
Photos: yes V
Waiver Attached: 6 no rr__
A building permit maybe required by: Gii�1 V`
( Note Local Planning Jurisdiction)
Notes/ Special Conditions �'� r�..,o„�- ( 0 (n�
Agent or App"ant Printed Name -�
(Scale: , " 7� Z of )
❑ See note on back regarding River Basin rules.
a IVIJ �-" VrA J AL/I %t^7f
C,h
Permit Officer's Printed l`
Signature Please read compliance statement on back of permit **
Signature
4k;u v• u v 1 1 1 1
Application Fee(s) Check # Issuing
-7/,A61-7

Date
Date
Check From
Name of Permit
Vendor
Check
Check
Permit Number/
Receipt #
Received
Deposited
Name
Holder
Number
_amount
Comments
5/17/2017
Walter Mark Stacy
William H. Cooper,
BB&T
1497
$200.00
GP 69197D
SF rct. 4245D
Jr.

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: 04A 0ef� U 1- - ( ` ,
o�%
Date: 11� 61 4 q
Describe below the HABITAT disturbances for the application.
All values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
Habitat Name
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
and/or temp
restoration or
temp impact
temp impacts)
im act amount)
temp impacts
amount)
D
Dredge ElFill [IBoth [IOther
(-b
i —�—b
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
Mailing Address:
41329 A IE -kT5 4::�E2a Y �n .
SA,..l -go &✓-) . dt- 1-75313
I certify that I have authorized (agent) I, 1n We -t, to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at)
This certification is valid thru (date)
-T
Property Owner Signature
Date

HAND DELIVER
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PMR/MOORING PILINGSa0ATL1FT/B0ATH0USE)
I hereby certify that I own property adjacent to W t,-, Am 4 - if oo P e r- `s
(Name of Property Owner)
property located at 3 z".k "014C) s-r.
(Lot, Block, Road, etc.)
on CA'tq V- , in 0CEA^1 l )La sat: RC -A N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: 4010 Mailing Address: 4 a2s ANEt-M C,
SAti.Fo f ► c- 2-1330
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
h& I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRA.W1NG & PkbPOggb VEVEY,OPNaNT:
(7o befilled in by individual proposing development)
5rE )
--------------------------------------
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit) W
� 9 z$ a14EN�s "'Eac4 Vb . �t
Mailing Address Signature
�5A#s4F0e0 14c "Z-1330 A -'' 4 N(kr YV V1e
City/State/Zip 11frint or Type N e
Gila - 7'1 7- L1 0 1 o f ...
Telephone Number
Signature Date
Telephone Number
Date

HAND DELIVER
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to 4 • Go ae, . FJ,e • 's
(Name of Property Owner)
property located at 32 2rc 44^1o ti n 6-1 .
(Lot, Block, Road, etc.)
on Cq L , in Or-C14 i St3 F<k& , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: 9 iq - -7-7-?- 4a1 0 Mailing Address: 4928 <4 VE uT5 fE2Q Y 2n .
5gal4,�'o.th r.✓e- Z733o
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (15') from my area of riparian access unless
waived by me. (If you wish to `naive the setback, you must initial the appropriate blank
below.)
I do not wish to waive
I do wish to waive that setback requirement.
------------- -------------------------7--- -----------------------------.........
------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
( Sff AkrrA-c4C--* �7Rqull�l Gt )
--------------------------------------------------------
(Information for Property Owner Applying
for Permit)
482 8 AqE-HITS fete y 2t) -
Mailing Address
5 �i eJ-rd a 0 , )4 e- 2 -13 3 0
City/State/Zip
It9- 7» - -f01 a
Telephone Number
A,u. "e.1-��
Signature Date
(Ripari n Property Owner Information)
Signature
Print or Type Name
r10 q40, 6 l 3 Q' ,
Telephone Number
Date

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