67139D - Cotton

]LAMA / ❑ DREDGE & FILL
1"ENERAL PERMIT Previous permit# A B
9New ❑Modification ❑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 15A NCAC
❑ Ru4 attached.
t Name 6 C! Project Location: County C
�A- L-7 Street Address/ State Road/ Lot #(s)
Vl/ A State N 4-- ZIP�"7 Z6'
E-Mail _ Subdivision
ed agent N City":� V' ` ZIP 27Q
E'71uCW / OTA El ES ❑ PTS Phone # () River Basin C�
❑ OEA /❑ HHF ❑ IH ❑ USA ❑ WA Adj. Wtr. Body 61AA el.'s 04 SC— n
❑ PWS:
yes /' io na PNA yes / )
Closest Maj. Wtr. Body 4�iu c C
Project/ Activity
:k) length
itform(s)
Platform(s)
I/ Ripraj%length
distance offshore
x distance offshore
cannel
iic yards
ip
illdozi V
Length`r "� 5
not sure yes nq
um: n/a yes o
yes no
attached: no
ig permit may be required by: L /
tacaie: ( d
❑ See note on back regarding River Basin rL
ocal Planning jurisdiction)

NC pIvi ® of Goat ,. Hl�iia impactcomputer *nee
Applicant:t
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.
S Ft F1RlAL Sq Ft. TOTAL Feet
Habitat Flame
DISTURB TYPE
Choose One
Dredge ❑
Fill ❑
Both ❑
Ot
------------
Dredge ❑
Fill ❑
Both . ❑
Otl
Dredge ❑
Fill ❑ :
Both ❑
Otl
Dredge ❑
Fill ❑
Both ❑
Ot
Dredge ❑
Fill ❑
Both ❑
Ot
Dredge. ❑.
Fill ❑ .
Both ❑
Ot
Dredge ❑
Fill ❑
Both ❑
Ot
TOTAL q.
(Applied for.
(Anticipated final
(Applied for.
(Ar
Disturbance total
disturbance.
Disturbance
d'rs1
includes any'
Excludes any
total includes .
Ex(
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
ten
tempimpacts).impact
amount
tem im acts
am
ter ❑
ter ❑ I I

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to -Ito-n i G(cncla I
(Name of Property Owner)
property located at '70 g'7 7� � .
(Address, Lot, Block, Road, etc.)
on '1`� Wyfe.�- rcLn --1 , in .SLu'f' f- , , N.C.
(Waterbody) (City own and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc io .
I have no objection to this proposal.
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
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.)
IUL10 I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner I formation) (Adjacent Pro n r Information)
Signature i ture *
A I Ian i fence Co t.4 h f-ee,^
Print or Tvoe Name Prim r Tvae Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ki tat, i G lea.. CA+kyl ,s
(Name of Property Owner)
property located at `iog % � 5+-
(Address, Lot, Block, Road, etc.)
on 11. Cared in i , N.C.
(Waterbody) (City/T wn and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc ion.
1 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 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.
(Pa7Ow er In�fo�rmat_ion)
r
S nature
A t la.n i Gnu. (ot}tn
(Adjacent Property Owner Inf rmation)

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