97977D - Campbell

° CAMA / 'J DREDGE & FILL
3�� (� �a��#9� A B C O
GtNERAL PERMIT Previous permit#
New - Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC Q 2�
❑ Rules attached.
7
Applicant Name ,�oins�k --(OIIM, earD �� Project Location: County /c1c�.) 4� aoayxX'
Address
City , .I m;•N4,b^ State Ak- ZIP 0?
Phone # (�/ ) E-Mail
Authorized Agent%rTr' pp;
Affected ❑ Cw 911EW I� PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes /ti no) PNA yes no
Type of Project/ Activity IC cp fo U t X: S_�,\ten Obn
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)� z) t/o X �fn
Finger pier(s)
Groin length
number
Bulkhead/ RipNoffshore
avg dist
max dis
Basin, channel
cubic yards=
Boat ramp
Boathouse/ Boatlift
Beach
Other
Shoreline Length J S
SAV: not sure yes no
Moratorium: n/a yes no
Photos: yes no
Waiver Attached: yes no
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIP
Phone # ( ) River Basin C F 9-
Adj. Wtr. Body Iq GJ (nat /nat /tnt
Closest Maj. Wtr. Body —
(Scale: I" r 30' )
A building permit may be required ed by: of (,) ; �4" ❑ See note on back regarding River Basin rules.
( Note Local Planning jurisdiction)
Notes/ Special Conditions te o 7 Z06 Q loe'aS4,a ( i cA,y ta*Q i\ S
6,400 (u.
i
Agent or Applicant Printed Name
Signature // Please read co}ri iance statement on back of pe�rrm( it �
�'(' 1 q �
Application Fee(s) Check #
l�rno ks ": h
Permi icer's Printed N
gnature
r)2/1�h 06113tIl-�
Issuing date I Expiration Date

,NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: 12d&,i Cameo Permit #:
Date:
02 it � �-
Describe below 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
in any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
�W
Dredge ❑ Fill ❑ Both ❑ Other
Z
impact
l Z
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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both Q Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
-)e'�_unu_73i t1s2 •• �1_ARA..A arnncr .. ..,..n..,.r•.-nae��I»,..a.,...,...,....,,..� ..off

Payment Proccessing Confirmation
Date Received 1/31/2017
Check From (Name) Pippin Marine Construction, LLC
Name of Permit Holder Robert & Holly Campbell
Vendor Wells Fargo Bank
Check Number 4146
Check amount $200.00
Multiple Permits No
Major/Minor
Permit Number/Comments GP 67977D
Receipt or Refund/Reallocated BS3441D

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent) _� !f 'L to act on my
behalf, for the purpose of applying/for and obtaining all LAMA Permits necessary to
install or construct (activity)/i��'j
at (my property located at)
This certification is valid thru (date)
REGElVED
JaN_3 0_2on

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to r}` ' �t z!% l Afn„ ,(f'%% s
(Name of Property Owner)
property located of
(Address, Lot, ¢lock, Road, etc.)
¢ r,-�N-C.
on in /�6
——(Waterbody) (Ci !Town acid/or County)
The applicant has described to me, as shown below, the development proposed at the above
iocati n.
i have no objection to this proposal.
i have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
1.
exrs7;y t . r
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 initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the IS setback requirement.
(Property Owner Information)
�tt ttr�--`�
Print or Type Name
6 PL, %:✓(eJ
Mailing Address
City.S""ate Z,p
9f�-,iis`ill�
Telephone Numberl email address
Date
`Valid for one calendar year after signature*
(Ad- nt Property O r Info ation)
�1"I'l—A
C
Srgnat re* vl,�)CI
vlk
Prim or a Name I
Mail [drme
A-J
C! (3ip �Tt 3Y 2
Telephone Nurriberl email address
Dale ` --
(Rawsed Rug. 201-4)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
s
~`'
I hereby certrfy that I own property adjacent to
(Name of Property Owner)
property located at. i %G'+L / -5
!, (Address, Lot,_ ¢I Ck, Road etc.)
on {s`ifi in �� %tirsr �i- � 1c N.C.
(Waterbody) (Ci [Town aria/or County)
The applicant has described to me
location.
I have no objection to this proposal.
as shown below, the development proposed at the above
i have objec`uons to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
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 initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(rty Owner Information)
7g. am'
Signature
,--Ar1- - a a,ode
Pri t or Type Name
Mailing Address Z-1G
.r
Citwstat ip
1/0 -.i%S- 60
Telephone Numberl email address
Date
nforrnation)
Prim or T p Nam
Mailing A dr set
Citylstat I`
Telephone ttvv��mber ernail address
�/f<�t-Z
Duce
(Revised Aug. 2014)
`Valid for one calendar year after signature'

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 1&141
. :
(Name of Property Owner}
property located at ��11G3
/c9ktf S �C"
(Address, LoL I.,ck, Road etc.)
on in /f///`l "O jG3, , /46 N1 C.
(Waterbody) (CitVrTown acid/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatisn
I have no objection to this proposal
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
arS-X' Y %rl/i�
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 npanan access unless waived by
me. (if you wish to waive the setback. you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Prop" Owner Information)
Siimature
PrintorTyp7eName
U J ,, r --,,, ,RV
Meding Address
p 141,lhit•tD� AC 2hrPtq
City/Sta ip
714 - S2-f"6/r ]
Telephone Number/email address
riry e�Lip ,� -2
Telephone Nurpberl email address
Dale
(Revised Aug. 2014)
'Valid for one calendar year after signature'