66565D - Bavgess

71CgMA / ❑ DREDGE & FILL CTi 11 I I� _ A B
GENERAL PERMIT Previous permit#
�Iew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
>rized by the State of North Carolina, Department of Environment and Natural Resources O '
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
- ( El Rules attached.
it Name ,t . G(V -1 �� Project Location: County /!S��>r
5 0 I Street Address/ State Road/ L`9t #(s)
2 i State ZIP1
lL E-Mail Subdivision
zed Agent LCAL\t City Ltwl �((A( ZIP_
p ii
i ❑ Cw ><EW )<PTA ❑ ES ❑ PTS Phone # ( Il0 ) `I �i O I p River Basin
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A Adj. Wtr. Body _ �' ( t
❑ PWS: I ^ / na
yes / �o PNA yes / Closest Maj. Wtr. Body ++ V
,f Project/ Activity
xk) length_
latform(s) r
Bngth
n nuv, --
id/ rap length
g d/ktance offshore
axAistance offshore
ibic yards
mp
(Scale: t
❑ See note on back regarding River Basin r
;k

NC Division of Coastal Mgt. Habitat Impact Com;
Applicant: ' I Avq-(
Date:
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
FIB
(Applied for.
(Anticipated final
(Applied for.
(An
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
dist
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
tern
tempaim acts
impact amount)
temp impacts)
am
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 ❑

-Amn. W,
NDE R
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue Braxton C. Davis Dee Freeman
Governor Director Secretary
AGENT AUTHORIZATION FORM
Date: 9 3 /S
Name of property OOwn��er Applying for Permit: Name of Authorized Agent for this project
t:
Owner's Mailing Address:
Phone Number(&M 904—/53¢
Agent's Mailing Address:
go
Phone Numberdg) 44y -gzal
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity);
For my property located at / "v ,� - , W, C'
This certriication is vafd thru (date) 3 /�
Property Owner Signature Date

16 2016 9:20PM HP Fax
page i
#AW+6 b4, Vtt,.
A.DJAC,'�JIV'T RD-ARIAN PROPERTY OWNER STATEMEN'�
(FORAPD-RMOCiMG pffjAjG,SW4n' 7YBO�4T° UU LLB}
I hereby kertiiv that .l c�wn `�'
�� ad3acenr Ua t
�fp4eownri.
property located at �✓ p},�Q 1_ n
(Lot, Block, Road, etc.) __ a
0n in
(V4`ateri3ody) --
{To n an or Conn# }
Applitaut'a. phone # Y —4V7�, � 'A, Adti,.. r
a Me, 4. k
He has described to me, as shown below, the devela
have no objections to his proposal. I and pro the proposujg at that location, awe I
erstand that. pier/mooring pilings I boatlifi / boathouse
must be set back a Minimum distance of fiftc n meet (I5D from my area of walvad bq me. Of you wish to Waive the setback, you
lbelovr.} must initial the approblankate blank less .
I d Ro L to waive
I do wish to waive diet setback requirement,
DESCRIPTION AND/OR DRAWING OF PROPOSED DRV-L0pjMMj
krRrorm$tioa for Property Uwuer +4ppl!'jn$
for Permit)
Aa
Mailing-!' A = '
City/State/Zip
-V6 - VdI. —I f $41
(Riparian Property finer Intonmation)
Signature
Print or Tvpa Iv mnr

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner
Address of Property. i J 0 d s ') Qce. , I-, v-.
(Lot or Street #, Street or r<oao, City a County)
Agent's Name #: Laev e 44 �.,C
Agent's phone #: 9/0-- e- 3— lidO
ci
Mailing Address:1 56 7 AKr k It
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
the re proposing. A description or drawing with dimensions must be provided with this letter.
`oi JA (',11 . 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.,
Wimington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no objection if you have been notified by Certified Mail.
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.
N
I do not wish to waive the 15' setback requirement.
(Propert�r Owner Injornration)
Signature
LQtue
Print or Type Name
(A - cent Property Owner Information)
k - - — S:�5 r-,� k
.Sig-n-- re \is4 a A 00 I0--y�
Print or Type Name

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