66536D - Burney

7 CAMA / ❑ DREDGE & FILL ` n Al �a 65►C 36 A B
3hENERAL PERMIT d / Previous permit#
New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued_
rized by the State of North Carolina, Department of Environment and Natural Resources
-oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
nn ❑ Rules attached.
t NameTnbti � - � V r n e `� Project Location: County (V (\ l / � (
P. Lt'i'�� J 11 Street Address/ State R ad/ Lot #(s)
C State � ZIP d�. lU ,�P �vv o D r.
E-Mail Subdivision C if (k 0 U i
:ed agent (1 C tl >M� r I �� p G\� L �cJ� City .S N �k Q �1�� ZIP_ 1 1
❑CW �EW PTA ❑ES PTS 1 �J` ��� Phone # (�)�y River Basin LAW l
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A Adj. Wtr. Body w W(at)/i
El PWS: yes / no PNA ryes) no Closest Maj. Wtr. Body
r Project/ Activity V
iwo
atform(s) I'
Platform(s)
ngth
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tuber
d/ Rip length_
di Ice offshore
uc dtance offshore
Sic yards
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not sure yes 0 OWPEMEN
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yes no HILMNINOin Is
ng permit may be required by: 0 SVY1�jt �Li El See note on back regarding River Basin n
Local Planning jurisdiction),.l \ _.1 ►� 1 a.,.

NC Division of Coastal Mgt. Habitat impact Corr
Applicant:
Date: t-{ /�1 �� (p
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
F
(Applied for.
(Anticipated final
(Applied for.
(/
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
d
Habitat Name
Choose One
includes any
Excludes any
total includes
E
anticipated
restoration
any anticipated
re
restoration or
and/or temp
restoration or
to
temp impacts)
impactamount
temp impacts)
a
Ov v
Dredge ElFill ElBoth ElS Other
(X' / S
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
n
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number:
Email Address:
&pot
I certify that I have authorized /
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: Z�-��n y / )A0X_r
at my property located at 1d 55 /ev,If,
in lT�r-; rtiJJ �xunty.
I furthermore certify that I 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:
I
r 6W4f,
Signature 1/
410
Print or Type Nam
Title

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property:
II(Lot or Street #, Street or Road, City & County)
Agent's Name #: ��/uJ 0�"%AC, Mailing Address:
Agent's phone #: _9Id-c)3
hereby certify that I own property adjacent to the above referenced property. The in ivi ua
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions, must be provided with this letter.
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. Contact information for DCM offices is
available athttp://www.nccoastaimanagement.netlweb/cm/staff-listinp orby calling 1-888-4RCOAST.
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, boat ramp, breakwater, boathouse, or lift 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.
7-1 do not wish to waive the 15' setback requirement.
(Property Owner Information)
p�
Signature
Print or Type Name
(Riparian Property Owner Information)
Signature
Ste; � Tra rTtiz,�ci.J
Print or Type Name
- /00 A, ox -/,/077
ICC SF�f,36LCCN e-v7

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property:
N
I(Lot or Street #, Street or Road, City & County) I '
Agent's Name #:/%i� ��r Mailing Address: �aao�d
Agent's phone#:
hereby certify that own property adjacent to the above referenced property. a in ivi ua
applying for this permit has described to me as shown on the attached drawing the development
they are roposing. MifilhoidiAl6n or r ` i6t
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. Contact information for DCM offices is
available at http://www.nccoastaimanagement.net/web/cm/staff-listing orby calling 1-888-4RCOAST.
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, boat ramp, breakwater, boathouse, or lift 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. i1 6 Hid;✓& I equez
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
�Aevk 6
Print or Type Name
Rip ian P operty Owner Information)
ign ture
10,toe 49yd
%iii(
Print or Type Name

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