66694D - Allen

ICAMA / ❑ DREDGE & FILL
xWNERAL PERMIT
New ❑ Modification ❑ Complete Reissue
�41"' < t!�'
Q
El Partial Reissue
A
Previous permit #
Date previous permit issued
B
ized by the State of North Carolina, Department of Environment and Natural Resources l r'
oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
❑ Rules attached.
Named 7 f ► Y`n A, Project Location: County
`p �j Eti Y 1 J ' - Street Address/ State Road/ Lot #(s)
State ZIP
(ni)-Mail Subdivision
:dAgent i� `����yC'}Z� ' M'4' t h City L/0 6*i1 I� t�(k ZIP gl'
VT
❑ CW ❑PTA El ES ❑ PTS Phone # (t' �) 1� O Riv Basin � uw
ElOEA HHF IH ❑ UBA ❑ WA
Adj. Wtr. Bodnat
El Pws.
ies / ho/ PNA yes //no I Closest Maj. Wtr. Body vv'
Project/ Activity
k) length J
tform(s)
'latform(s)
igth
fiber
/ R iprap length
distance offshc
c distance offish
innel
Ildozing
Length - 0
Jm: n/a yes o (
yes
ttached: yes no
g permit may be required by: _
ocal Planning Jurisdiction))
❑ See note on back regarding River Basin
C

NC Division of Coastal Mgt, Habitat Impact Computer Sheet
Applicant: T-1,v R
Date: 01 A I
/�-o ( �
Permit #: � � � q �4
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
TOTAL Sq. Ft.
FINAL Sq. Ft.
(Applied for.
(Anticipated final
DISTURB TYPE
Disturbance total
disturbance.
Choose One
includes any
Excludes any
anticipated
restoration
restoration or
and/or temp
temp impacts)
impact amount)
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
Disturbance
disturbance.
total includes
Excludes any
any anticipated
restoration and/c
restoration or
temp impact
temp impacts)
amount)
t l e; A I I Dredge ❑ Fill ❑ Both ❑ Other jr I -A q--7 I I 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 ❑
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 ❑

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue Braxton C. Davis
Governor Director
AGENT AUTHORIZATION FORM
Date: 0 ^ r
f `
Jame of Property Owner Applying for Permit:
Mtn & e e Ugj,
)wner's Mailing Address:
��ettev��je /�fC
2� 30 3
'hone Number ( Q (Q q?'4P , 617 �L
Dee Freem
Secreti
Name of Authorized Agent for this project:
Agent's Mailing Address:
H5 = 2798 Sea Vista Dr.
CONSTRUCTION Supply, NC 28462
Phone Number
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
)r and obtaining all CAMA Permits necessary to install or construct the following (activity):
13�� uF-r ad C0QWA(.
or my property located at '7 3 W �UT«64xi/� , 005 2opcf61
his c rtification is valid thru (date)
Property Owner Signature Date

US MAIL
CERTIFIED MAIL, -- RE' TURN IREWEIP'r REQUE§TED
DIVISION Or COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPEXTY OWNER STATEMENT
f r . A.t ,
Name of Property Owner;
Address of Property:
Applicant's phone #���
V7
Mailing Address: � qo(.q I ' f✓art Jf-�
�kvll (z I K c'- -0 �03
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this permit
has described to,rme as shown on the attaelded drawing the development they are proposing. A dgwription of drawin
wit di a s' n§ ntust be provided with this letter.
Z— I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM)
in writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.
Wilmington, NC 28405-3845. DCrY1 representatives can also be contacted at [phone], No response is
considered the sane as no obLection if you have beep notified by Ceriifiedi Mail.
WAIVER SECTION
I understand, that a pier, dock, mooring pilings, breakwater, boathouse,_or lift must be set back a minimum distance of
15from my area of riparian access unless waived by me. (If you wish to waive the setback, you must initial the
appropriate latik below.) jnIM
M ` 8 i Ste,-"ce o�
I do wish to waive the I5' set back requirement. •P1 Ce6Vt5 +6 { �ro•- w..Y u�' e-G 4
�1 "QK
I do not wish to waive tho I S' set back requirement.
(Property Owner Information)
Signature
Yp
Print or Type Naime
iv1R ing Address
1P
(Riparian roperty Owner Information)
Signature ) j
Print or Type Name
Mailing Address
rntrf�v1 n)c _ U

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to I ��� l�Alm s
�� III ) _ r,t (Name o Property Owner)
property located at
myl-
(Addres's, Lot, Block Road, etc.)
on C,(AVI(A-1 in C-_rr- .IliL C1 N.C.
(Waterbody) (City/Town and/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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
-Y
C�'lM t� Ga'LtitC� I I ��S
WAIVER SECTION
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.)
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Si nature -1 u Ai len
Print or Type N4ne '- ,
(Adjacent Property Owner Information)
Signature*
MAM I I
Priat 9r ,Type Nam r s

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