66311D - Addonisio

LAMA / ❑ DREDGE & FILL
;ENERAL PERMIT
New ❑Modification ❑Complete Reissue ❑Partial Reissue
ized by the State of North Carolina, Department of Environment and Natural Resources
oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
r !�,� /�/ / ❑ F�ples attached.
Name i&Pi(A Id 7 t ��� 4611 / S l G Project Location: County 1 .��a r ©Lt1
7 ;�- C-p4l -e IP ref • Street Address/ State Road/ Lot #(s)
o 14 1 State AC ZIP
7 y 4-Mail Subdivision
Bd Agent
❑ CW �O EW A
ElOEA ❑ HHF ❑ IH
❑ PWS:
yes / no PNA e5 no
Project/ Activity
i
:k) length .z
itform(s) � 6 _ -
Platform(s)
er(s)
igth
fiber
V Riprap length -- -
distance offshore _
K distance offshore
annel
do yards
ip
se/ Boatlift
r
illdozing
i
a Len S
A B
Previous permit #
Date previous permit issued
1" ,
City' C i//I
l r''� C..
ZIP,
❑ES ❑PTS
Phone # (--j----
River Basin L�z
❑ UBA ❑ N/A
Adj. Wtr. Body
/
nat
Closest Maj. Wtr. Body�`'�
rn
(Scale:
not sure yes nb"
D
um: n/a yes
-..-......_...
yes no
atached:
ig permit may be required by:
_ocal Planning jurisdiction) ,
❑ See note on back regarding River Basin ri

NC Division of Coa�,tal.Mgt. Habitat impact, Computer Sheet
plicant:
' S
tte:
:scribe below the HABITAT disturbances for the application.
I values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft.
for.
FINAL Sq. Ft.
(Anticipated final
TOTAL Feet
(Applied for.
FINAL Feet
(Anticipated fina
DISTURB TYPE
(Applied
Disturbance total
disturbance.
Excludes any
Disturbance
total includes.
disturbance.
Excludes any
ibitat Name
Choose One
includes any
anticipated
restoration
any anticipated
restoration and/
temp impact
restoration or
ternimpacts)
and/or temp
im act amount)
restoration or
teMP im acts
amount
❑ Mil ❑ Rnth r-1 Other ICI '�
1 -2— K
Dredge
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge. ❑. Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other 171

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Req
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
Z �j
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
in �� County.
1 furthermore certify that 1 am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
1J �
Signature
Print or Type Name /
'41CI61)11 S7_0
%A
Title
/ t A A A. 1, 1 1

T
I hereby certify that I own property adjacent to
property located at / 1") -� ( Ir-y-
on
in
O _ (Na of -Pro erty Owner)
Lot, loc ,_Road, etc.) '
4:�e z 6-f N.C.
(waterbody) (City/?6wn and/or CBuniy)
The app cant has described to me, as shown below, the development proposed at the above location.
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 vrt description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to waive
t e setba 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.
( roperty Owner I rmation) (A lac n e ormation)
Sig a it Si ' mature
Pn*nt or TyeName Prin or Typ am g
O �
Mailinrn drlrinacc /I &4drnce J

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to E � i re ova ( S•' O s
(Name of Property Owner)
property located at 1 Z7I C4 V&e- .t— L L,t e
(Address, Lot, 8 ock, Road, etc.)
on , in L , N C.
(Waterbody) ( !Town d/or County)
The applicant has described to me, as shown below, the development proposed at the above location
_ I have no objection to this proposal.
I have objections to this proposal i
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill description below or attach a site Swing)
r'
Ll
�eNq x w,1( he r rt
=4) I
E� WAIVER SECTION
I understand that a pier, dock, ?Mooring pilings, 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.
1 do not wish to waive the 15' setback requirement
rty Owner I rmation) (Adjacent Property Owner Information)
—idIL4U&
rr Signar
/ t T
Tye Name Print or Typ4 Name
Address/' r / �--^ Mailing Address
6 V & Z[� court 1i A
tdl7in 1, 1 ?-i1V/Sfahm121n — '