66617D - Besecker

t j /
JCAMA / ❑ DREDGE & FILL I� v I ��� !' J";
3hENERAL PERMIT ' Previous permit # r,
lNew ❑Modification El Complete Reissue El 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
- ',`,qq Rule"s�attached.
t Name K FSC le- Project Location: County j , QI
,k . o-,- Street Address/ State Road/ Lot #(s)
^O
State (\k -. ZIP 7S460 i_! % 4- /.yi A
fMb-)S -� �16_.0 E-Mail
ed Agent TO Vl K C- < Sri I
❑ CW EW )CfTA ❑ ES ❑
❑ OEA OHHF ❑ IH ❑ URA ❑ N/A
❑ PWS:
yes l'&o ; PNA --lEe"D no
' Project/ Activity
Subdivision
Cityj/1 �a S
Phone #
Adj. Wtr. Body 1�
Closest Maj. Wtr. Body_s
� ZIP
River Basin
flat,
0
(Scale:
ck) length r i
itform(s)
AW
Platform(s) -
nber
i/ Riprap length_
distance offshore
x distance offshore
l
cannel
sic yards
1p
Z
Adozing
Length / \1
not sure yes no
cum: n/a yes
yes
ktached: yes no
ig permit may be required by:
_ocal Planning jurisdiction)
❑ See note on back regarding River Basin n

N% Division of Coa�;talNg/t. Habitat impact. Computer Sheet
10 '
Applicant: 1"QI11--
Date: 17/
Describe below the HABITAT disturbances for the application•
All values should match the name, and units of measurement found in your Habitat code sheet.
Flh
TOTAL Sq. Ft. FINAL Sq. Ft. TOTAL Feet (An
for. (Anticipated final (Applied for. (An
(Applied Disturbance dist
DISTURB TYPE Disturbance.total disturbance. total includes. Ex�
includes any Excludes any
Habitat Name Choose One
anticipated restoration any anticipated res�
restoration or and/or temp restoration or ten
_.v_....a� 4vmn iennnnts) am
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 ❑

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date / �
Name of Property Owner Applying for Permit:
Mailing Address:
/ Q j A11 r
S)1eY-Ss Ferry, C &4 ba
I certify that I have authorized (agent) -
to act on my
behalf, for the purpose of applying for and obtaining all CA
MA Permits necessary to
install or construct (activity) — 1111kA
at (my property located at) i 8 3 4(l y2 -a r .24t_� Af r y Al C
This certification is valid thru (date)
-/N e ! , a 10) 6
Property
P rty Signature Data

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to r.J zoa>C/ I
ame of Property wner)
property located at 1.�,3 y L4414eit 6&
(Address, Ldt, Block, Road, etc.)
on / in N.C.
(Waterbody) (City/To and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locat
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)
/d)i 9,
BJkf I-Jf
6 do( y
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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
(Adja nt o
rty Own r I f
mation)
S7j—n atur -e
gzs e c_�'f
Sig a e
t'L
Print or T)Ipe ame
P -h br T e a

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to _ 7' e3ki.-`' I
(game of Property O ner)
property located at
/041K, ^- (Address '
A dress, Lot lock, Road, etc.)
on , in -tiJ N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
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 rill in description below or attach a site drawing)
I, ids I
J i 6'(d O
0 o—
joy
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
e. (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) (A cent Property Owner Information)
Si atur S*wgture
Prin or Typ Name Print dr T e Name