67178D - Bannerman

1,4AMA / ❑ DREDGE & FILL
�ENE❑MRALon PERM❑pITSSUe
) e L ilfll� . �.
❑ Partial Reissue
A B
Previous permit #
Date previous permit issued_
rized by the State of North Carolina, Department of Environment and Natural Resources 1 nn
-oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC ()� }� � � U
El Rules attached.
it Name _64ftkIMAProject Location: County (gmy Vr`i i—
a Ivy Street Address/ tate�R°oad!/ Lot #(s)
C State 41
E-Mail V Subdivision
:ed Agent F— V j C0CityZIP
❑CW ,SEW D TA ❑ES ❑PTS
❑ OEA ❑ HHF r❑ IH ❑ USA ❑ WA
❑ PWS:
f Project/ Activity
)ck) length_
latform(s) _
Platform(s)
wgth
amber
id/ Riprap length
g distance offsi
ax distance o
hannel
ibic yards
MP -
use/ Boatl
4
ie Length .�
not sure yes o
rium: n/a yes
yes
Attached: yes no
ing permit may be required by: _
Local Planning jurisdiction) n
Ph ne River Basin ✓V w
Adj. Wtr.w
Closest Maj. Wtr. Body
(Scale: ,
�,vv� ❑ See note on back regarding River Basin

NC Division of Coastal Mgt. Habitat impact Computer Sheet
Applicant: �p�-�h�� Permit #: 6-7
Date:
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/or
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other 0
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge [I 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 0 Fill ❑ Both ❑ Other ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address: fie' elt 5 W
Phone Number: 910 23 2. - C} b 7�
Email Address: 110ti42,111,
I certify that I have authorized
Agent t Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
in I (a 1',""k, "Cy— County.
z
1 furthermore certify that 1 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:
` � h
Signature
Print or Type Name
Title

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:
U J 4 ,✓.✓ r r- i` 4�
(Lot or Street #, Street or Road, City & Cou
Agent's Name # /li�'_� ��S�cS i� Mailing Address: � /--AS% c
Agent's phone #: / -36 3--: Ye .�` ec-,+- 0_l /3 / 14a �,,V,Y-94
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 deveiopmeni
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 athttaJ/www.nccoastalmanaoement.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 Cert/i!kt1 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.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Ripari n Property Owner Information)
Signature J, Si nat e C
g f I
Print or Type Name <" Print or Type Name

y CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Prop
erty Owner: ��i� � ��d cr- %4 fa.✓
Address of Property:
(Lot or Street #, Street or Road, City &
Agent's Name
Agent's phone #:
Mailing Address: ,,� Y u
I hereby certify that I own property adjacent to the above referenced property. The individ
applying for this permit has described to me as shown on the attached drawing the developm,
they are proposing. A description or drawing with dimensions must be provided with this lefte
(fix 1 have no objections to this proposal. I have objections to this proposal.
Ifyou have objections to what Is being proposed, you must notify the Division of Coastal Managem,
(DCM) In writing within 10 days of receipt of this notice. Contact information for DCM offices
available at htta:/Arvww.nccoastaimanaaement net/web/cm/staff-listing or by calling 1-888.4RCOA.'
No response Is considered the same as no objection If you have been notified by Certttied 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.
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)
Signature
(Riparian Property Owner Information)
�y
aagc loq.� �,C
Signature
/ C �A o �v
Print nr Tvnn At -

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