67262D - Brown

CAMA / ❑ DREDGE & FILL
'ENERAL PERMIT ►
1 Previous permit #
New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources
'oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC / ' r ' 17 0 U7 1
El Rules hed.
Name r . 6 1�(/V ✓1 Project Location: County & V YK:t F-
a 4M Street Address/ State Road/ Lot #(s)
S Ci- State SiIP'�y�tt 10� s
b E-Mail Subdivision
�d Agent
❑ CW
❑ OEA
)EW PTA ❑ ES ❑ PTS
❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
res / po ; PNA yes
Project/ A tivity
OAiA,
k) length
tform(s)
'latform(s)
:r(s)
gth
fiber
/ Riprap length_
distance offshore
c distance offshore
innel J
P.
e/
Length --I VJ )
notsure yes no
(a (x
City —Jib `AW ZIPS
Phone # ( River Basin Z-Um
i
Adj. Wtr. Body I�V1 nat
Closest Maj. Wtr. Body
TVA Ar
(Scale: I
im: n/a yes41
-
yes
[[ached: ye$ no
g permit may be required by: Gctiin pt' �4v � C.N k�(' ❑ See note on back regarding River Basin ru
ocalPlanning jurisdiction) nn, 'd _-1 d IN
j I j

NC Division of Coastal Mgt. Habitat Impact Con
Applicant: 60I b7 i eaw rl
Date: (6/0- ft �
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.
(f
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
impact amount)
temp impacts)
a
Dredge ❑ Fill ❑ Both ❑ Other
7,
Ld
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

02/07/2004 19:20 9108429806
1,REG FiOLLDE I
� � � �' ram.• : v
Name or Individual Applying For Permit:
Address' of Property: _j -.2% -? A
(Lot 'or Street Street or
PAGE hl
v�
, City County}
I hereby certify that I
r�Qnced property- The individuaproperty adjacent to the above -
bed to me zs shown ors the attacbead lying for this penit has
they are proposing. A description or drawvin9 the davelo
should be ovided with this n9, with dimensions,
ietteSr.
I have no objections to this proposal_
houusndd* tatnd that a pier, dpek, Uoorin
frog - must bee sat9 pilings. brGa-Xvater, boat
to aY axeaa at riparian access back a minimum distance of 15
valve the setback unleesss waived by sea.
below.) You Z initial (If You wish
the appropriate blank
I de wish to waive the 15"setback requirement-
-- i IQ -I= wish to waive the 15'setback requirement.
S a ur@ �o� • � 1I
P t Name C Date
---�— Q10 4-77 _ -1 /n ��.....

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to aw" I
--, ( ifieofPro erty Owner)
property located at Y
(Address, Lot, ock, Road, tc.)
on in Ir7j IL Metc � , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above locati
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill 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 bac
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to w,
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)
Sign re
"I
Print o1,Type( ame
(Adjacent Property Owner Information)
` or. Type Nam r�

n