67188D - Crystal

-XAMA / L L DREDGE & FILL
3"ENERAL PERMIT I f /`-1 Previouss mit A B
peremit # �
�New ❑Modification ❑Complete Reissue ❑Pa ial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources 'I !�yyam�
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC (�'14 L�'�`'�
j�.� j�, ; ❑ les attached.
t Name S'� 'JVU (e1 L Project Location: County- low
U (/ 5; 0 Street Address/ S Roa Lot #(s)
D/ u 1 State �t ZIP N116 Cr n r l ✓ %�
OA-)
Z �' lj E_ I Subdivi ion /� &
ed Agent / jGI City �0 ZIP �'LU
❑ CW )dEW )JYTA ❑ ES' ❑ PTS - Phone # () River Basin f'
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ WA Adj. Wtr. Body N An'a'7t-V,
❑ PWS:
yes / no PNA yip no Closest Maj. Wtr. Body' O'/
61
' Project/ Activity
■■■■■■ ■■■ ■■■■■■■■■■�■■■
t11■■■■■
■■■■■■■NONE■■■■ ■■■■■■■■■■■■■■■
1,r , ■■■MER ■■ �MM■■NEE■■■■■■■■■■■■■■■NONE
NI
distance offshore ■■
ngth
RIM
...�,sZ■■NN.M�.-M.■■ i■KEM■INK
■.�
'ic yards
v 1
se/ Boatlift
�(dozing
-■■■■��■■■■■■■■■■■■�iliLSifctl3L'rl`■is�.iSl■■■■■■
■■■■■U■■■■■■■■■■■■■■■®■■■■■!1■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■
MO��a■■■■■■■■■■■■■ :■■:■:EON: ■■
■■■■■■■■■■■ ■■■■■■■■■■■■M

NC DIVISIOn Oi `I-Ma-sv fa1'.1111waa 9RGl9i7a
Applicant:
Date:
l� application.
.
Describe below the HABITAT disturbances for the app.
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. (Ani
DISTURB TYPE Disturbance.total disturbance. Disturbance disti
inclades any Excludes any total includes • ExG
Habitat Name Choose One anticipated ' restoration any anticipated rest
restoration or and/or temp restoration or tem.
Dredge ❑ Fill ❑ Both ❑ Others
Dredge []'Fill
❑'
Both. ❑
Other ❑
Dredge ❑
Fill (]
: Both ,❑
Other El
Dredge ❑
Fill ❑
1 Both ❑
Other ❑
Dredge ❑ Fill ❑. Both ❑ Other ❑
Dredge. ❑. Fill ❑ : Both ❑ Other ❑
;; Dredge ❑ Fill 171 Both ❑ Other 171

Eck Proccessing
ifirmation
Received 1 11/1/2016
* From (Name) High Tides II NC, John Hamme
ie of Permit Holder Crystal Shores c/o Johnny Sides
for Bank of America
-k Number 2642
-k amount $200.00
iple Permits No
it/Minor
nit Number/Comments 67188D
Apt or Refund/Reallocated JD/24931D

II, Jason
n: Johnny Sides <[e-mail]>
t: Wednesday, November 02, 2016 8:49 AM
Dail, Jason
ject: Re: Agent Authorization
Dale: all of that is correct. I am vp of the homeowners association
: from my iPhone
my Sides
(336)-462-0727 {24/7)
Vov 2, 2016, at 8:41 AM, Dail, Jason <[e-mail]> wrote:
Good morning Mr. Sides. Could you please confirm you have authorized Forrest and Elizabeth Hamme
(High Tide Builders) to act as your agent, on behalf of Crystal Shore/Osprey Drive HOA, to apply for
any/all CAMA permits for modification to the existing community docking facility?
Please respond at your earliest convenience.
Thank you
Jason Dail
Field Representative
NC Department of Environmental Quality
NC Division of Coastal Management
127 Cardinal Drive Ext.
Wilmington, NC 28405
Phone: [phone], Fax: [phone]
Jason. Dail@ncdenr.a v
<image001.png>
E-mail correspondence to and from this address
may be subject to the North Carolina Public
Records Law and may be disclosed to third parties.

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to c
property located at
on
in
The applicant has described to me, as shown below, the development proposed at the above
location.
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
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 YVQU 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.
rty Owner Information)
nt
AUV- 2JUL)�'��l
Signature
A O K T:iiuUak�
Print o T pe Name
f DS PQhtl

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Cr ( Q,S
n (Name of Rroperty 01
property located at
(Address, L cQ y
, in
The applicant has described to me, as shown below,
location.
I have no objection to this proposal
I have objections to this proposal
I
✓/ t4- ` 0
ock, Road, tc.
N.C. `
(City own and or County-
the development prop d at the above
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
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.)
"1 I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Informatio& c� (Ad' ent Property Owner Information)
i atur SignatG)—a
W'e'
P ' T Name Print or Type Name
�s �1 0�'Or-� ��

Scope of work:
Make repairs to the existing walkway to gazebo and rebuild damag(
----------- - -- - - — - - -- --