67165D - Brown

`CAMA / ❑ DREDGE & FILL 14 L' //
/ J A B
3ENERAL PERMIT Previous permit#
JNew ❑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 15A NCAC
❑Rules attached.
Name W, �C D U.7 N Project Location: County
/ I'4 C'ru Street Addrfess/ State Road/ Lot #(s)
7 Lj State / ZIPG
(LN ` � � E-Mail Subdivision
:d Agent '41 vbz+. � � D /► � S City � CZIP �� C -T
❑ cW WW )QPTA ❑ ES ❑ PTS Phone # River Basin
❑ OEA 6 HHF ❑ IH ❑ UBA ❑ NIA Adj. Wtr. Body VV A -T:Eg S 64q nat
❑ PWS: _
res /"no PNA yes / no Closest Maj. Wtr. Body
Project/ Activity
:k) length
tform(s) .
Natform(s) V I
er(s)
igth
Ober
/ Rlprap length
distance offshore
c distance offshore
annel
is yards_
P
e/ Boatlift
Length
not sure
yes
im: n/a
yes
no
yes
no
F
ttached:
yes
no
Y LvU, v� s
g permit may be required by: U
CAM—
,ocal Planning jurisdiction)'
(sue: t 11,
❑ See note on back regarding River Basin
- L ,Lf- - . . -

NC Division of Coastal .Mgt. Habitat Impact C®MpUtor sheet
Applicant: CA6t /L
Date: g' 5— / 6
Describe below the HABITAT disturbances for the application.
All values should match the name, and units of measurement found in your Habitat code sheet.
TOT -Sq. Ft. FINAL Sq. Ft. TOTAL Feet FIf
(Applied for. (Anticipated final (Applied for. (Ar
DISTURB TYPE Disturbance.total disturbance. Disturbance dis
Habitat Name Choose One includes any Excludes any total includes . Ex(
anticipated restoration any anticipated res
restoration or and/or temp restoration or ten
+amn imnn&s) am
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge []
Fill ElBoth
❑
Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge. ❑.
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other 171

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Appl
Mailing address:
Phone Number:
I certify that I have authorized 4
A n / o ractor
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of CL47?e
A
at my property located at
in County.
This certification is valid through ^'
Date
(Property Owner Information)
C'
Signature
Print or Type Name
R�,Cj4ijVE
Title JUL 2 5 2016

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at
ME
(Waterbody)
I
(W;ime of Property Owner)
(Address, t, Block, Road, tc.)
in , N.C.
(City/To n and/or County)
The applicant has described to me, as shown below, the development proposed at the above locati
I_, I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fit/ in description below or attach a site drawing
PUVz
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set ba
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) (Adjacent Property Owner Information)
Siiature Si ature _
Print or Ty�pe,� e Print or Type Name
1317 G u I� w�q i 2 GL 1iL3 ►2

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to 's
4 of Property Owner)
property located at
(A dress, Lot, BI ck, Ro , )
, in
on
N.C.
(Waterbody) (ci#Town and/or ounty)
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 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 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) (Adjacent Property Owner Information)
Signature Si ure
Print or Type Name Print or Type Name
�ecp 'le � Pl 1' 0127

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