66547D - Boucher

ICA, MA / ❑ DREDGE & FILL
GENERAL PERMIT 'V Previous P1ermit# A B
�NeW ❑Modification El Complete Reissue El Partial Reissue Date previous permit issued
•ized by the State of North Carolina, Department of Environment and Natural Resources i1 /
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC G /'% l 21OG'
rr-L&GI hed
t Name / 11 lkpw ljer.
State ZIP
E-Mail
ad Agent U1!3r OO? y 414-t4
❑ CW 514W VPTA ❑ ES ❑ PTS
OEA ❑ HHF ❑ IH ❑ URA ElN/A
ElPWS:
yes / no PNA yes no
Pro' ct/ Activity /2!�,al
'' ' f11
:k) length
tform(s) h -1
—
Natform(s) I I I{
igth
nber
I/ Riprap length
distance offsh5
c distance off
annel
is yards
P
Ildozing
Length ZY2
not sure yes no
im: n/a yes no
yes io
ttached: yes 6/
es atta/c
Project Location: County Ake,,
Street Address/ State Road/ Lot #(s)
Subdivision
City �l�hir►'�/� ZIP
Phone # ( ) River Basin
Adj. Wtr. Body��/��(natM/���(n7a�tt k
Closest Maj. Wtr. Body 4141-�% <A
y/?1111-i;
(Scale: ///
g permit may be required by: ky C-e, ❑ See note on back regarding River Basin
ocal Planning jurisdiction)

NC Division of Coastal Vgt. Habitat impact : omputer ShOOt
Applicant:
Permit #: S� —
� � � �%UC'i�
Date:
Describebelow the
HABITAT disturbances for the application.
All values should
match the name,
and units of
measurement
found in your Habitat
code sheet.
FINAL. Sq. Ft.
TOTAL_ Feet
for.
FINALFeet
(Ant(cip aW
TOTAL Sq. Ft.
(Applied for.
Disturbance total
( *113ated final
d(iurbanoe.
(Applied
Disturbance
disturbance.
Habitat Name
DISTURB TYPE
ISTURB One
Chooseanticipated
includes any
Ec udes any
total includes
any anticipated
Excludes any
restoration and/or
restoration or
restoration _
ar0rtemp
amount
restoration or
temp impacts
temp impact
amount
temp impacts)
impaof
nliz
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 M Both ❑ Other ❑
hfo.4A r"i Kai F1 Rnfh n Other ❑
_

NCDENR
North Carolina Department of Environment and
Division of Coastal Management
McCrory Braxton C. Davis
Dvernor Director
Natural Resources
John E. Skvarla,
Secretary
AGENT AUTHORIZATION FORM
Date: 3 :Z i I L
ie of Prope Owner Applying for Permit: Name of Authorized Age for this project:Ar
ier's Mailing Address:
t�a 10/ J r o
A,Cry �iJ rV C 2 0 Ci It
ie
Agent's Mailing Address:
C 'L YVo 3
Email: ee"
Phone (C7'10) ;�-3/-5'5/V
tify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Permits necessary to install or construct the following (activity):
„y property located at
certification is valid 1 year from (date)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that 1 own property adjacent to; �r/ ' f{.�ur,Lt y s
i (name of Property Owner)
property located at
on
(Waterbody)
(Address, L Block, Road, etc.)
in Li:'J: �� ra <-.— /'—C , N.C.
(City/Town andfor 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 DRA1i4ING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
��IjNS-
r
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 waiv
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.
(Property Owner Information) (Agacen property Owner Information)
sign c�tur�' _Cc � Sikxiure
Print or Type Name /�/ /J Print or Type Name
Z' � ice/ LJ; < C- I cv: J/' J�F J e.

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to s
(name of Property Owner)
property located at � ) d
-It-
(Address, L , Block, Road. etc.)
on in i�, -lam_ C N.C.
(Waterbody) (Cityffown and ar 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)
eP I
1
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.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
/ ✓ ! `X
.SI (/ to — I �+ C
C eQ6 G Ae�� S, o e.0 Cc
Print or rypq Name f Print or Type Name

RECEIVED
APR t 4 2016