67279D - Blakinship

&AMA / ❑ DREDGE & FILL �/' �Y
PENERAL PERMI
T Previous permit #
New ❑Modification El 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 k
'FiyJes a shed.
Name ` �Y , ��-t Project Location: County
Street Address/ State Road/ L`ot� '#(s)
State ZIPW Id"11 it
�y � � E-Mail 'V C' �, MA Subdivision
ed Agent liA, City `- '�� ZIP
❑Cyy AS PTS Phone # River Basin 11
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ N/A - , � I
Adj. Wtr. Body �(L�'�t �� ��!�'� (, W�I[t
❑ PWS:\ V V
yes / no PNA yes �no j Closest Maj. Wtr. Body
' Project/ Activity
a� .
:k) length_
atform(s) _
Platform(s)
ngth
tuber
d/ Riprap lengthLOO�
distance offshore
uc distance offshore
cannel
bic
np-
ise/
l
ie Length ;
not sure yes no
rium: n/a yes % ..........-. I
yes no
Attached: yes
ling permit may be required by: ` t! Local Planning Jurisdiction)
✓! 1
❑ See note on back regarding River Basin i
,A I -

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant:
Date: f
�I
Permit #: Ul )Tl
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
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.
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/o
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge El 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 ❑ Both ❑ Other ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
L r�
/- 11 N N PLA
Al X US H i,10
Mailing Address: 107 Stu
C2 T
Z SL`
Phone Number: �i/��" -Sy/S'
•-- 3 3 'IL/
Email Address:
1 certifythat I have authorized
L c.c
Agent /
Cbntractor
to act on my behalf, for the purpose of applying for and all CAMA permits
��o}}btaining
k'
necessary for the following proposed development: o"C*tti
� � �2
� � S
- s � ,
-2 8 Yk
at my property located at j �%
in () p tLNStvt *-, County
l 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.
Owner Information:
- - - Signatufe
Print or Type Name
rive

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIA ROPERTY OWNER NOT ICATIONMAIVER FORM
Name of Property Owner: jL "�' /� IlJh1--/U lGIIU sf�/,
Address of Property:
c2 (,;�' &nx- -Ts1-Axi) C
(Lot or Street *, Street or Road, City & County)
Agent's Name #: aU-)&"b M A1Z 1 k)1bZ Mailing Address: 9,21 /""t AR-0L4 --t
Agent's phone #: 9) 0
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 deveiopment
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 at http •lAvww nccoastaimanaaement netlweWcmistaff-listinrt or by calling 14MB-4RCOAST.
No response is considered the same as no objection If you have been notified by CertHled Mall.
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.
I do not wish to waive the 15' setback requirement. ; /atftt� WrOX 54
(Property Owner information)
Ygnalure 41 W"'11--
7rint or Type Name �, � h -D (?'1 kx5
LP
I! I"
0.;z 9
(Riparian Property Owner Information)
Signature i
i r) .,I- t e,
Print or Type Name j

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIA"ROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property;
Sit)a 7. C
J)U&�Voo
C-269
(Lot or Street S. street or Road, CW& CmnV � 31/ 7E C1/--r
Agent's phona
i hereby oartify that 1 own property adjeoent to the above referenced property. The individual
applykV for this penr* tw dem bed to no ss shown an the attedxd drwnMtr�,#ve deveio�rnertt
"Yam proposing,
no objections to this proposal. i have objections to this proposal..
tf you have 04kw 0m to wftW jW h@&gPeapom4 you must na* fhe Dh4ska o(Co*SW Xansgem&W
(w* 1n wrift wid* !8 fte sf pn*t of tMs not *. Copied hObnoNMa for DCM 000" trs
�� arby�attinp 14*94RCOAST.
No msomme is cor>afiMend t1» asrnr ss no *-Vctbn if you have bow nodal by Certtlfed U011.
WAIVER SECTION
i understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or trtt must
be set back a minimum distance of 15' from my area of riparian access unkM waived by me. (if
you wish to waive the setback, you _Mttst fnit.ial the appropriate blank betow.)
I do wish to waive the 15' setback requirement,
s�
I do not wish to waive the 16 setback requirement.
(Property Owner Information)
• • � : ► G �ii� �
I�
(Riparian Property owner Infomation)
�'dz,e d kt -- -1'-�- --7
Signature
Cot /' /M .1 2-7
Pint or Type Nauss 2 3 4/- Z'�5
<!� 64'/ /Merrde-,f)7a/%mil

�c 14(C.
5
�, PC, PA ),�
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