67932D - Castleman

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NC Division of Coastal Mgt. Habitat Impact Comi
Applicant:
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.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FIN
(Applied for.
(Anticipated final
(Applied for.
(An
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
dist
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
rest
restoration or
and/or temp
restoration or
tem
temp impacts)
impact amount)
temp impacts)
am(
Dredge ❑ Fill Both ❑ Other ❑tJ
Dredge ❑ Fill Both ElOther ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both 0 Other 0

3ayment Proccessing Confirmation
Date Received 11/9/2016
heck From (Name) Mark Clements
Name of Permit Holder Howard Rockness
Vendor First Citizens Bank
Check Number 4238
Check amount $800.00
Multiple Permits Yes
Major/Minor
Permit Number/Comments GP 67933D
Receipt or Refund/Reallocated JD/3402D

Letter of agent
I 66,9:!1 Q. CA55 C—e'"N have retained Mark Clements DBA, Clements
Marine Construction Inc, to make application for any and all permits needed to start
construction on the work requested for our property or properties.
By allowing Mr. Clements to make such applications I do understand that this will in no
way relieve me of any obligations to perform all work according to the building codes of
North Carolina, CAMA, DWQ or any other state and or county ordinances.
Print name
Siig�nnaatune
33G " 7v'1-3Z7 a date Z-j1C
Contact information

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to AA I-E, Z Cgg IA4&A, s
—(Name of Property Owner)
property located at
(Address, Lot, Block, Road, etc.)
on , in , N.C.
(Waterbody) (City/Town and/or County)
The a licant has described to me, as shown below, the development proposed at the above
loc
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)
ie. " cevlolgc 1
Z,�',e .6-, 5
/es ')(10,447
1�s5�IMa�
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.
(Prope Owner Information)
Signatures
,i?XAi
Print or Type Name -
(Adj996nt P
Information)
Print or Type ypme
e � y 13 i4-cp f4 6 c- e- L4-n'�

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to.r' ns5t��it�d/l _ _ I
t f 11 (Name of Property Owner)
propertylocated at....__.._....._z...�...._._..__.—_^.._..._..___._� ...._........_
{Address, Lot, Block, Road, et _
on f� C G' �v' in Ali 20,47J - r1e i3 i1so1< N C.
(Waterbody) CitylT'own and/or County)
The applicant has described to me.. as shown below, the development proposed at the above
ioc tia on _
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
�o�x�1 r�sf%�Msi,�cf
I k 100 ' 1
ilk -
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathgusw--lrft, tS-rgrorn
must be set back a minimum distance of 15' from my area ofrra'cc s unless waived by
me. (if you wish to waive the setback, you must ini ' 1-the appropriate blank below.)
I do wish IQ -waive ffie 15' setback requirement.
I do not wish to waive the 15' setback requirement.
{Property Owne)nform0ion)
-:.. s tr�llC- tart
Sig ulrrre -�
I '2XI eW-
Print or Type Nar e
Madnq Address
�rryi rdfe�z,iJ
Telephone Number/email address
Owe
(Adjacent Property Owner Information)
-----.........
Print or r y e Name
M� ,ng Address
Cit / r8re%Zip
4A(:( l 7— 3Z7 v
Telephone Number/ email address
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