66675D - Bynnside

�CAMA / ❑ DREDGE & FILL )�v
3ENERAL PERMIT
(New ❑Modification ❑Complete Reissue ❑Partial Reissue
A
Previous permit #
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 �� ` I ' �. o
❑ Rules attached.
t Name �� Vh 51 � Project Location: County C�L : -w S &
V Street Address/ State Road/ Lot #(s)
C� l� a,w-e State i(Y`-� 1 `� �� `
5 �3 E-Mail Subdivision
ed Agent L 0, V° V` S , �A( �Mi � City D t Q �A ZIP
❑ Cw NPw )JPTA ❑ ES ❑ PTS Phone # (1� ) �' �� ( ° River Basin
❑ OEA Ef HHF ❑ IH ❑ USA ❑ N/A 1, I
❑ Pws. Adj. Wtr. Body ! ` ,UJVV at r
l ��LVOC i PWA Closest Maj. Wrr. Rudy
Pr 'e Activity
:k) length
itform(s) a 1
�% . it
es
rg permit may be required by: 1 Uwe O T \ ZAJt/ti. f5 See note on back regarding River Basin n
.ocal Planning jurisdiction)

ABC Division of Coastal Mgt. Habitat impact Computer Sheet
Applicant: Vyy�s Permit ##:
Date: GO,
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)
I FINAL feet
(Anticipated fine
disturbance.
Excludes any
restoration and/i
temp impact
amount
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 ❑
Dredge ❑ Fill ❑ Both Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

Pat McCrory
Govemor
AkVA - -
am
North Carolina Department of Environment and Natural Resources
N.C. Division of Coastal Management
John E. Skrr
Swett
AGENT AUTHORIZATION FORM
Date:
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
Lai ne_ �ILVVNS
Owner's Mailing Address:
Email:
Phone
Agent's Mailing Address:
mod KAv RU
Email: nL S C4 YYu• 0
Phone (_ ly ) 9(4 3 -I-I'Y
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for, and obtaining all CAMA Permits necessary to install or construct then following (activity):
/�f / 0 1P. 9w.A A a Ti�IJ� �K
For my property located at I S Z 44 lc k
This certification is valid 1 year from (date) Y, //, el A 4::,

Wu \1.) 61 �'O
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I herebY certify that I own property adjacent to ��� A i,e s 'IC4-
property located at
on _:;gc, Ly
(Waterbody)
e of Property Owner)
I
(Address, Lot, Block, R ad, et //
in �4'2..� cL1 N.C.
(City/Town 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 AND/OR DRAWING Or PROPOSED DEVELOPIMEN T
(Individual proposing development must hl1 in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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 u wi h to waive the setback, you must initial the appropriate blank below.)
i do wish to waive the 15' setback -equirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjlle
ope Own e Information)
Signature � w �� � S�gnulur� � 2

l
ADJA&-NT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ,J,
property located at 7 Z
on :;g' tj �
(Waterbody)
bi
of Property Owner)
I
(Address, Lot, Block, R ad, et
in 14,,;.17e c , N.C.
(City/Town and/cr County)
The applicant has described to me, as shown below, the development proposed at the above
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)
�2, D Q-"—' �- J—
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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.)
/K I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature l 4w e- Aa Xi-5
Print or Type Name
9©-7 ^/. 5. L)
Owner(Adjacent Property

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