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Home My WebLink About66594D - BuskirkICAMA / ❑ DREDGE & FILL 3JENERAL PERMIY ew ❑Modification El Complete Reissue El Partial Reissue A Previous permit # Date previous permit issued rized by the State of North Carolina, Department of Environment and Natural Resources -oastal Resources Commission in a area of environmental concern pursuant to I SA NCAC . ^ 1 �7 Rules a/ t Name ►' "! /� / c. 1, Project Location: County —2y l� �/'/ {�'Z'� �t �,Gt-r+ { Street Address/ State Road/ Lo%/#(s) 14 ovM %i State ZIP 2 fj�p�/ �� '/t'.a��J ter' L 3 ,� _ r' /� y�,S��y�� Subdivision :ed Agent ,err,/�i City �/t//!�%�61�h�ih ZIP 2�00 U� CVN giv* 0116A DES ❑PTS Phone # ,River Basin ❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A ❑ PWS.G DAdj. Wtr. Body YJ/J•'' nat �/ no PNA �/ no Closest Maj. Wtr. Body S � ng permit may be required by: 14 1� re. 7/; S ❑ See note on back regarding River Basin r Local Planning jurisdiction) y —410/ ,� �' �i r, szC t =b w At AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION Name of Property Owner Requesting Permit: /�� LD�!e� SUSS/.� Mailing Address: L / �-4r-f-6- Phone Number: 39 2 - 7-?0--T Email Address: I certify that I have authorized , Agent / Contractor to act on my behalf, for the purpose of applying for and obtaining all CAMA permits r" r necessary for the following proposed development: o!'/ /C V"/ at my property located at in ^/, County. 4-/OLV Gelqr✓ 1 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 l`,I! cyle�� 'Zel Print or Type Name Title I hereby certn5r that I own property adjacent to /1 L� �21�z s V 5 </ l s (Name of propengr otuner) property located at 554- (Addrazz, Lod Mock,, R®ad, etc.) Dn in (WataFbady) (Ci17frown arndlor County) the applicant has described to me, as shown below, the development proposed at the above location. 'V I have no objection to this proposal. I have objections to this proposal. (individual proposng d evetopMeng musg O041' in descrripopn below or aVach a g¢8e draw§ngi j :i WAVER SECTION understand fhat a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back a iinimum distance of 15' from my area of riparian access unless waived by me. (if you wish to waive ie setback, you roust initial the appropriate blank below.) 1 do wish to waive the 15' setback requirement. [do not wish to waive the 15' setback requirement. 'ropany owfleP Infonnation) (Adjacent krippeAY 0VM Ieifou nation) Si e inf or Tvoe Name Print nr Tvne . a t i ! 7 ADJACENT RIPARIAN 'PROPERTY OWNER STATEMENT hereby cer6ni/ that I own property adjacent to M 1�� Ve t 's (flame of ProperW Owner) roperty located at 3 S'�4- / ;� i �nl � � � ��= (Address, t.o4 Block, Road, etc.) n C_ Y`J , in 1\14-,A_l ��4yelme, 46alk�,7- V.C. (Waterbody) (Cityfi'own and/or County) he applicant has described to me, as shown below, the development proposed at the above location. / I have no objection to this proposal. I have objections to this proposal. DESCRIPTION AND/OR DRAINING OF PROPOSE® DEVELOPMENT (individual proposing otevelop.77errrt musff Dell in de<vcriptibb below or attach a site drawing) yy 4} WAIVER IECTION inderstand fhat a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back a nimum distance of 15' from my area of riparian access unless waived by me. (If you wish to waive setback, you must initial the appropriate blank below.) 1 do wish to waive the 15' setback requirement_ , [ do not wish to waive the 15' setback requirement: roperrlty Owner Information) r jC11_1/_d , z1 �4wkyLkl 7iiature 'it or TvnP Name . Sag�gturee Print nrr Tumn Alnmv ADJACENT LZIPARIAN PROPERTY OWNER LTA1 EMENT hereby certify that I own property adjacent to property located at 3 5"4- FR I L!W D I ✓+"�°��►=� (Name of Propel Owner) I (Addrazz, Lot, BIock, Road, etc.) >n in _/�i �� fi^�+��✓ CQyo✓L"`/ , N.C. (Waterbody) (CityiTown and/or County) the applicant has described to me, as shown below, the development proposed at the above location. I have no objection to this proposal. I have objections to this proposal. DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPP91EN:F (Individual proposing development musg Oil in description below or affach a site drawing) S /h�G-+T--.D L3 I "JG S WAIVER SECTION inderstand That a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back a inimum distance of 15' from my area of riparian access unless waived by me. (if you wish to waive e setback, you must initial the appropriate blank below.) I do wish to waive the 15' setback requirement. , (: do not wish to waive the 15' setback requirement. ropers Owner Information) (AdjOcent ?tzp Owner Infomation) r ,glature Si zat O ev J nt or Type Name _ Print or Type Name ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I hereby certify that I Um property adjacent to property, located at 3 S4- !✓� r r �1 b c. (Address, Loft, Block, Poa&, etc.) on j C YJ , in _ Mf%o✓ C�t/N1"'/ (Waterbody) (CiWITown andlor County) I N. c. The applica has described to me, as shown below, the development proposed at the above location. 1 have no objection to this proposal. I have objections to this proposal. DESCRIPTION ANDIOR DRAINING OF PROPOSED DEVELOPMENT (lndi0diva1 proposing deve.oprpent must rill in descriptlgn helotu or if each a site drawing) WAllVER 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.) t/ I do wish to waive the 15' setback requirement., 1. do not wish to waive the 15' setback requirement: (Property Owner Infonnation) C.PaI? ltd , A G� GCD%Z1iZ �� Si' :!nature ,J /1171LD44 Print or Type !Name = 3s� f=�1 r�� L y/ Lhr✓C (AsDjaceeat`Plto, rty Owner Information) Signature Print or T e Name /// �� NC Division of Coastal Mgt. Habitat Impact Computer Sheet Applicant: % (�%/ /�CC��S`�S/r Permit ##; �V Date: 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) FINAL feet (Anticipated fins disturbance. Excludes any restoration and/i temp impact amount 1� v Dredge [IFill ❑ Both ElOther Dredge ❑ Fill ❑ Both ❑ Other 12- 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 �3 Other ❑ Dredge ❑ Fill ❑ Both ❑ Other ❑