67223D - Case

ICAMA / ❑ DREDGE & FILL i�l� 7 / 67223 A B
31ENERAL PERMIT Previous permit#
(New ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
rized 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 674, ) � 0 0
CC�� ❑ Rules attached. tName�� a.�t�yw'� Project Location: County 96M -IC-1 ILI^1T L
% C_Ok` f Street Address/ State Road/ of #(s)
Q,State ZIP
(� q )I) ^ PI E-Mail —" "� Subdivision
ed Agent / V 10 y\ — � _ �� City AAc k ZIP.
❑ CW 'EW XPTA ❑ ES ❑ PTS Phone # �) River Basin
ElOEA "XD HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
yes / Qo PNA yes /
Project/ Activity
:k) length_
itform(s) _
Platform(s)
igth
nber
I/ Riprap length
distance offsho J
x distance offshore
annel 1
sic yards
ip
se/ Boat
Length `^
Adj. Wtr. Body not r
Closest Maj. Wtr. Body
- ■■,�■�:■CNN■r���■tlll
0". Way, Fri 1,14
IL
i1irli�� �■
(Scale:
❑ See note on back regarding River Basin rL

NC Division of Coastal Mgt. Habitat impact Computer Sheet
Applicant: C a �� Permlt #: O a a 3
Date: 09 /A � Aot
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 FINAL feet
(Applied for.
(Anticipated final
(Applied for. (Anticipated final
Habitat Name
DISTURB TYPE
Disturbance total
disturbance.
Disturbance disturbance.
Choose One
includes any
Excludes any
total includes Excludes any
anticipated
restoration
any anticipated restoration and/or
restoration or
and/or temp .
restoration or temp impact
temp impacts)
I impact amount)
tem impacts amount)
Dredge ❑ Fill ❑ Both ❑ Other
sC(
�V
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 El Both El Other ❑
Dredge [I Fill El Both [I Other ❑ .
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑

HCDETIR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
ly Eaves Perdue Braxton C, Davis
'nor Director
AGENT AUTHORIZATION FORM
Date:
of Property Owner Applying for Permit:
►vies n�)c.oh, 112-ASe_
s Mailing Address:
D Gqr �, s+';
re, i (.. . C. 2?la a
Number %q) 34 °I OR 1 1
Dee Freemai
Secretar
Name of Authorized Agent for this project:
A^4 H oru
Agent's Mailing Address:
H 5 = 2798 Sea Vista Dr.
CONSTRUCTION Supply, NC 28462
Phone Number (11 O ) 8 21—koro
that I have authorized the agent listed above to act on my behalf, for the purpose of applying
obtaining all CAMA Permits necessary to install or construct tthe following (activity):
1_ CA G l" n. to- % l c 4-1- .1n A O 1 C V 4*. A 6 r- - ; V&v :Z%+V'q S+4 i
-fie r w 4 W ..
property located at 3 0 -S am of k e Lci #%,e Id a UaK 8eq to c Zpy
rtification is valid thru (date) �"'eC��^^-b`'' 3 , 20 �O
Property Owner Signature Date

To i✓ A.; �
I hbreby certify that I own property adjacent to Chap �'o �-� - �0,se I
s �^ ^� �U�� (Name of Property Owner)
property located at So ? �-C ' l(1X
�� ,n -ad
(Address, L Bock, Road, )
1 �'�Q t .
on `� , in lC YU wt �,(� , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location �}-
$ �V `
I have no objection to this proposaI361
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)
RE'.vv1 o v� EY-s. s-�JaC"
C� o �k cL� ) c.'
5 e c .
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.)
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) Adjacent Property Owffr Information)
"U16TIk, I
a a uxe G �1 �S L C9S�'�KI�ItCCQ�
Print or Tvne Name „ . Print or-TvDe Name_ n ' i I r' i _ T

i
ADJAr.CNT RIPARIAN. PRQECRTY OWNER STATEMENT
t horeby COM4that I own prtspeMj adjaeon! to >`,
( a me of Property Owner)
property bated w 30b J14n11 2—&-vi I/—_ 7
(Address Lot Mock; Ro etc.
NC
(Waterbady) _�__ ,......e. (City/Town andl6r C*unty)
Tno apMiranl r?ii4 .'=ow4�C�![ood in .-� ", '4l'Y. itin 0olowtrix-t propos at 'ho above
tOt;B'
I have no objector, to INS priarxt-sa;
_. i ha.a esb,'4twtian:R fa thm Aropcsal,
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing deve)opmerif must fill in description below or attach a site drawing)
4
WAIVER §ECT12N
underslano-alt a per, moving wai ramp. vemkv crier, ooaitause. tt't, cr grun
rr V be set bac,c a rt jm.,n m distance -if l 15 from, my area rat riparan arc s i. nlocs wa�i>bd by
e, (tt you wish to wa.ve the sett, ya .l must initial the avr1roarVe blank bi w.
t 5' selback re; wireme w
i do not w sh t; vrai e ;he ? 5' settrar?c per I rf rrsar,
(P Owna formation) (Adjatent Prope+ty Owner t rmativn'
Ara Clef IL
ti Fz1f xr i*7cl li c 1
fSSCuL.�,,f-r Sfi.
f Ad,*trss ei 7 Ad toss
.sue.._ r�%♦ .
C r srx► r�.t e t
I , , If, lY, '2016
aaltr f onf, �,al#"ar �€ar ..4Kp svva1eirc,'

16-1 tb
v
X u
Z�tl v

r
i`"
F