69082D - Champlin

�,CAMA / DREDGE & FILL QN�-1,5.I�j
' A B C D
E N E RAL PERMIT Previous permit #
Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources J
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
r� ,� ( ❑ Rules Attached.
Applicant Name i�i%&NIa' C4°MPLA� Project Location: County ^ ':CC'k
Address VL) Pit 2
City State 4;;A— ZI P
# (D -2%S� E-Mail
Authorized Agentj�'L
Affected ❑ CW #W W'TA ❑ ES ❑ PTS
AEC(s): ElOEA ❑ HHF t IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes /e5 PNA yes /( o
Type of Project/ Activ7' %�-
LC)' i -t.
Pier (dock) length
Fixed Platform(s)
Floating Platform(s) V
Finger pier(s)_
Groin length
number \
Bulkhead/ Riprap length
avg distance offshb e
max distance offsho
Basin, channel
cubic yards
Boat ramp 1
Boathous*'foatli - r�� r 3
-i
Beach Bulldozing
Other
Shoreline Length - !
SAV: not sure yes no
Moratorium: n/a yes
Photos: yes n
/ Waiver Attached: es ) no
Street Address/ State Road/ Lot #(s)
`U o A r
Subdivision
City z 1 P ZfS44a
Phone # River Basin G ��--
Adj. Wtr. Body,- /Xr!'LS OP T (nat<j!�unkn)
Closest Mal. Wtr. Body T °�` C ?�G'ti 0
67" AV i//;
A building permit may be required by: T (2p5g&
( Note Local Planning jurisdiction)
Notes/ Special Conditions
(Scale:
PIS.
❑ See note on back regarding River Basin rules. `.
Agent or Applicant Printed Name jermitOfficer's Printe�Name
Signature**Please read compliance statement onbackofpermiJt** Yatu
t�---
Application Fee(s) Check # (1fl)ssuing Date Expiration Date

Date
Date
Check From
Name of
Vendor
Check
Check
Permit
Receipt #
Received
Deposited
(Name)
Permit Holder
Number
amount
Number/
Comments
3/31/2017 Allied Marine Gregg & Donna First 5331 $400.00 GP 69081D 1 of JD rct. 3893D
Contractors/Hal Schmidt Citizens 2 @ $200
Fogleman Bank

NC Division of Coastal .Mgt. Habitat Impact. Computer sheet
Applicant: }� v ►v
Date: ('—
Describe belohe HABITAT disturbances for the application.
and Wilts of measurement found
All values should match the name,.in your Habitat code sheet.
TOTAL Sy: Ft. FINAL. Sq. Ft. TOTAL Feet FINAL Feet
(Applied for. (Anticipated final (Applied for. (Anticipated final
DISTURB TYPE Disturbance.total disturbance. Disturbance disturbance.
includes any Excludes any total includes. Excludes any
Habitat Name Choose One anticipated restoration aiey anaiciP opd temp impactnd/or
restoration or and/or temp
ternimpactsimpact amount tempirri acts amount
1� 1�
Dredge [I Fill ❑ Both ❑ Other ✓
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ . Both ❑ Other ❑
Dredge ❑ Fill ❑' Both ❑ Other ❑
Dredge ❑ Fill Q Both ❑ Other ❑
r
Dredge. . Fill ❑ : Both ❑ Other
❑❑
,r f
Other
Dredge ❑ Fill ❑ Both ❑ ❑' �.

A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date a� 7
Name of Property Owner Applying for Permit:
Mailing Address:
0
I certify that I have authorized (agent) %r Q�LoQle—mckn to act on my
behalf, for the purpose of applying for andobtaining all CAMA Permits necessary to
install or construct (activity) Aoc-k -7sb ` co—T 1;�'l ,
at (my property located at) Il d L3Q I' k., k A e- — / DPscf BeGCJ
This certification is valid thru (date) ' Z - 31 — 1
Property Owner Sign
Date
400 Commerce Avenue, Morehead City, North Carolina 28557
Phone: [phone] FAX: [phone] Internet: www.nccoastalmanagement.net
An Equal Opportunity 1 Affirmative Action Employer — 50% Recycled 110% Post Consumer Paper

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to b it X,1 t Ck e " 11 tin is
(Name of Property Owner)
property located at
(C
(Lot,'Block, road, etc.)
on
C&n , in a l t �� N.C.
(Waterbod�y) ( own and/or County)
/
Applicant's phone #: "[ tip 3(ol 02(5 i Mailing Address:
He has described to me, as shown below, the development he is proposing at that to ation, and, 1
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
70f I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
Mailing Address
'wm��� /LTG
City/State/Zip
?,/0 �& 7 .2 (S�
"Telephone Number
7
Signature
Date
(Riparian Property Owner Information)
Signature
�T'11onuEs Gi• �fo�me
Print or Type Name
Telephone Number
Date

mar iv it 14.1up vrxry viulyml
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PLE"OORMG PILINGSIBOATLIFTBOAMOUSE)
I hereby certify that I own property adjacent to ha /! ch44411Y1 's
(Name of Propert Owner)
property located at
(Lot, Block, Road, etc.)
on q �fl L , in 1 �9a1e°� , N.C.
(Wr'aterbody) (To andlor County)
Applicant's phone #:
Mailing Address: �D b x Z $a
A 3-Ds-
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.)
T 1 I do not wish to waive
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To beft'lled in by individual proposing development)
-, /. Y 4
(Information for Property Owner Applying
for Permit)
Mailing Address
n1�G
City: State/7.ip
q(o 3Co� v1L� 1
Telephone Number
UkL
(Riparian Property (honer Information)
,..�'•: � :.�i�_ �,. i i_%� :fit=,l' �
gnature
n r-
r l )�
(..
i3nnt or Type Name
Telephone Number
Signature Date Dam

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