67963D - Bonsall

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NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: �SQi✓\ S oud
Date.
Permit #: G-7qc, �— C
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measuremen
found in your Habitat code sheet.
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
I FINAL Feet
(Anticipated fins
disturbance.
Excludes any
restoration and/i
temp impact
amount)
l7
Dredge ❑ Fill j$( Both ❑ Other ❑
11000
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 ❑
Dred�[[:31Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

layment Proccessing Confirmation
Date Received 12/9/2016
:heck From (Name) Jerry Mills Construction Inc
Name of Permit Holder Rick Bonsall
Vendor First Bank
Check Number 1651
Check amount $400.00
Multiple Permits No
Major/Minor
Permit Number/Comments GP 67963D
Receipt or Refund/Reallocated SF/3477D

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
n
Name of Property Owner Requesting Permit. -
Mailing Address:
Phone Number: -2o y - ")- — /&Y L( i
Email Address:
I certify that I have authorized _� ,� j, GC5 ,
a
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: -':F-) "'A //,j
at my property located at
in f--1. ,l•n County.
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:
% Signature
,V11
�J dNSAI�
Print or Type Name
Title

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PRL-OPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner. -
Ad d res s of Property: Skim rill-y ► '.2 G'r /,a ��� ;Z`? .2
(Lot or Street #, Street or Road, City & County)
Agent's Name #: Mailing Address: y`y�(v OCcml�- c Z�K
Agent's phone #: k, z-1 -t 3 ' �ty3 S
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
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. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wilmington, 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.
I do not wish to waive the 15' setback requirement.
(Props Owner i �rm�i i %Lr n A Y
Signature
�GuatLa it iT lys,(4 L L
Print or Type
s� Name
�,'d3 h/�!/Lt�t/iG
Maa1iling Address
(Adjacent Property Owner Information)
Signature
Print or Type Nance
-1/1 L/ z 5J � " �►,� �,�.._,._
Mailing Address

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to AI'A-11 /'S/).1'a Is
{Name of Property Owner)
property located at l ,� /, c �,.� 14 ,�
(Address, Lot, Block, Road, etc.)
on , in 426-e.-74-2 7-;,ic, 6-:1c , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above locatior
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)
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 wain
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 Pope Owner Information)
Si alure Si au e
Print or T}'pe Name Prinj or Type Name
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