69043D - Couington

�JCAMA / _ DREDGE & FILL P� 3 clt� ,1 1 A B C
GENERAL PERMIT Previous permit#
''New —Modification Complete Reissue 'Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources 7
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC�� C' V
' ❑ Rules attached.
Applicant Name �� A � (i Gk I h L n ' iy V + Project Location: County ► f�ms
Address 1 ¢� `7 . Street Address/ State Road/ Lot #(s)
City k State ZIP t � 5OAJ
Phone # ( ) E-Mail
Authorized Agent 6 �" W e 5
Affected ❑ Cw AW XPTA ❑ ES ❑ PTS
AEC(s): ❑ OEA O HHF ❑ IH ❑ USA ❑ N/A
❑ PW&
Agent or Applicant Printed Name
Sig ure ** Please read compliance statement on back of permit **
lob on I1-59M15351
Application Fee(s) Check #
Subdivision
City C ((f V1 1�K f A[ k ZIP —I
Phone # ( ) River Basin La 4-c'r
Adj. Wtr. Body C [ l N 6 at an unkn
Z14 1,A./
.� �� ✓l �a yr e i
Permit OfficerPrint e
Signature
n'�h ho1l oh�60
Issuing�-bAe T irratio�te

Date
Date
Check From
Name of
Vendor
Check
Check
Permit
Receipt #
Received
Deposited
(Name)
Permit Holder
Number
amount
Number/
Comments
3/23/2017
Wells
Money Order from Fargo 17-
John West Linda Covington bank 543995351 $200.00 GP 69043D SF rct. 3797D

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: / , VN 4
Date: 6-3 A -/-�,D
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)
impactamount)
temp impacts)
amount
W
Dredge [IFill [IBoth ElOther
q 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 ❑

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date /— /Z —1 %
Name of Property Owner Applying for Permit:
lNDA cot/W G-nA%
Mailing Address:
2 6; Lhl-;E 91D,=
,&CkrriONhq, AlL 2e✓72
I certify that I have authorized (agent) �,(�L S��G C to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) L)64< -]�- Chad
at (my property located at) �(��/v:�Q� S✓ ��—�T �� •
This certification is valid thru (date)
Property Owner Signature Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFT/BOATHOUSE) I hereby certify that I own property adjacent to lArDh 6V/P� 0-at/ 's
('Fame of Property Owner)
property located at' � ,B/ &rS 9
/- (Lot, Block, Road, etc.)
on CAAL, in CCMtjBQan�ScJIO�N.C.
(Waterbody) (Town and/or Cou ty)
Applicant's phone #: Ctt a —20` 07/7 Mailing Address: I2J5 44ATSIAP- DR
i�� . n1C 2�3Ts
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 picr/mooring pilings / boadift / 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.)
�V!!� I do not wish to waive
I do wish to waive that setback requirement. .
---------------------------------------------------------------------------------------------------------------- --
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
r
Ca NCRr--iF---------------------
(Information for Property Owner Applying
for Permit)
Z25 Z,4,4VE
Mailing Address
>ZCcor,� "f�ei m
City/State/Zip
G - (;7�7
Telephone Number
(Riparian Property Owner Information)
Signature
i rw-r- Alt f" M /0 O e ee-
Print or Type Name
%,0 - yr 7_/_
Telephone Number
Signature Date Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFT/BOATHOUSE)
I
I hereby certify that I own property adjacent to 's
(Name of Property Owner)
property located at
(Lot, Block, Road, etc.)
on �1.�_ in ��h-�}*�1 -i 5L�C�unt5(a�[, N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: I -20(-'0 7/2Mailing Address: 12-5 [AkEsIVE
Af Z
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
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
L
--------------------------------------------------------
(Information for Property Owner Applying
for Permit)
/25� .5,104 DR -
Mailing Address
City/State/Zip
Ala -- 20C—
Telephone tuber
Signature
Date
8
(Riparian Property Owner Information)
z
Signature
Print or Type Name
ct to — 54-o — Zl JF/
Telephone Number
Z-oi i2
Date