66540D - Bryant

Jr -AMA / DREDGE & FILL
3'ENERAL PERMIT Previous permit#
klew [:]Modification ❑ Complete Reissue ❑ Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources h
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC (OD t I' � � V 0
El Rules attached.
t Name \ I 6N CA,�' Project Location: County
Street Address/ State Road/ Lot #(s)
w YN State ZIP
( ) 3 (o-7 rJ3�SE-Mail Subdivision
ed Agent VV ` 11 �► Z V R Y d s6 ✓1 City 1�. t�—it GiV \ ZIP l'
❑ CW 50TA ❑ ES ❑ PTS Phone # (�) C � S —' r t River Basin 1—V�A
❑ OEA ❑ HHF 6 IH ❑ URA ❑ N/A
❑ PWS:
yes / , no PNA yes /
f Project/ Activity
ck) length
atform(s)
Platform(s)
ngth
tuber
d/ Rip length_
F
g distance offshore_
uc d)'stance offshore
bic yards
np
Adl. Wtr. t5od U V I
Closest Maj. Wtr. Body v"
ro
not sure yes -
ium: n/a yes
........
._
yes
Attached: �� no '-- I cif � I ,,
ing permit may be required by: I �W %` 'lda✓V1 ! 7L �� r t
Local Planning Jurisdiction)
(Scale: 1 1, =
❑ See note on back regarding River Basin r

NC Division of Coastal Mgt. Habitat Impact Coml
Applicant:. ��((V\� e'j (Ql h
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
Fit
(Applied for.
(Anticipated final
(Applied for.
(Ar
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disl
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
ten
ternimpacts)
impact amount
tem impacts
am
�V
Dredge El Fill El Both El Other
`� %
`\Q
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

NOMI UM1111d 1&WIUIIUIL to U IVsyv11111c1u Gifu 1tiaw"n 11WVYWV
Division of Coastal Management
Beverly Eaves Perdue ,lames H. Gregwn
Governor Dimlor
AGENT AUTHORIZATION FORM
Date:
Name of Property Owner Applying for Permit:
l ��i•1
Owner's Mailing Address:
l�1 Iff�rt"n,'� �►'
Phone NumberM)
Dee Freeman
Secretary
Name of jAuthorized Agent for this project:
Agents Mailing Address:
Phone Number ! U V)
I certify that l have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits
`�nt�fa�i4L,'� t�• %I
to instalt or construct the following (activity):
(my property located) at _ Y ',S 94- r L : • _�
This certification is valid thru (date)
t
._
Property Owner Signature Date
127Cardmi Orin Ext.. W**4 n, tC 28405 Platt bCar(�T1a
nr...,a• ni r0CR.77i R t FAX: 910395,V64 tnten a www.n0M3e W agementnet Al . i..... �l..

property located at _ �k p {
(Lot, BIock, Road, etc.)
(Waterbody) (Town and/or County)
Applicant's phone #: e 4�-/,, -M!:rMailing Address_ 1� `, �cr► ; t-
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 / boatlM / boathouse
must be set back a minimum distance of fifteen feet (15D from my area of riparian access unless
waived by me. (Hyou wish to waive the setback, you must initial the appropriate bl zk
below.)
I d o rent wish to waive
SS" I do wish to waive that setback requirement
• DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(T'o be filled in by individual proposing devefo"pmeny
� l�L.^�
(Information for Property OvMer Applying (Riparian Property Owner Information)
for Permit)
Mailing Address
�� .
city/�tataz
�'Ie1t��ic �uttiber
Signature Data
Signature
Print or Type Name
7;1-P-0-627q
Telephone Number
Date

.�-'_._.._ _^yam;.�.1\w •r oaf
.0,0 , Block, R(aad, etc,)
yy (W'sisrbody) ♦(ToiM AAdfor Couty)
��i L : i� .L� Y✓�✓ ^ f J J`. ,1tA=�a17A�j IMa�i : R l I i :� tic
He hss desm''bed to m4, as *4wa below, the devakopment be is propooing at tbAt ion iUM, aod, I
hs►te na objertioos m his pirogosal. I untl�tuidflut apica�aaosing piiingsli�catii� / boethou�+
nmat be set back a mz MIan distance of fiftean feet (15� from ray araa ofrapad= am "I=
xaivnd by me. (If you wish to waive the aatbacU, you 2MO inft%j the gprapriate blank
below,)
r i a not V&hdo waive
to waltiti that setback requirornant
-DPSCRIMON Ah'1?lOD DPAWM OF PROI?'OSO DEYnoIrA' j T: �.
(Ib be fWed In by tnt{lvtdawipropcalrrg devttopnreny
upt
a&0�-
Owbro on for Proper OW%W 4p7tuB
for 7ermit)
AA &g Addnss
4�"' �:ZFi1bQr j
�1
Signeuro Daft
C4-+k
(Riparin Owaer In*
Ar,
c L;��
I'rErlt or'i yj* Nam'
Ttf��Os Number
��1

North -=
16,-9 3/4"
13 I UP
m
posed L — — —
3'-3"
FF
I I
Existing 5tructures