66680D - Clewis

CAMA / ❑ DREDGE & FILL
r
` A B
ENERAL PERMIT rI " Previous permit #
New ❑Modification ❑Complete Reissue El 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 15A NCAC • 1 u
1 , ❑ Rures attached.
it Name V��y`�� Project Location: County I
Street Address/ State Road/ Lot #(s) 1
State ( 1 ZIP WLQI tw
Subdivision
:edAgent City_ZIP
L
❑ Cw ;&w \4 PTA O ES ❑ PTS Phone # ( )` River Basin
❑ OEA ❑ HHF ❑ IH O USA O N/A Adj. Wtr. Body nat
yes /no PNA yes / no Closest Maj. Wtr. li y �t
f Project/ Activity
(Scale: { I�
ck) length_
atform(s) _
Platform(s)
ngth
tuber
d/ Riprap length
3 distance offshore
ix distance offshore
cannel
bic yards
np _
1 Boatlift
ulldozing
e Length _-
not sure
yes
ium: n/a yes to
kttached: ves nc�
ng permit may be required by: ❑ See note on back regarding River Basin ri
Local Planning jurisdiction)

C Division of Coastal F419t, Habitat Impact Computer Sheet
plicant: I /J �U (S Permit #: (OU (05C
te: C
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
ind in your Habitat code sheet.
bitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/c
temp impact
amount)
CDredge
❑ Fill ❑ Both ❑ Other
(- I '\
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 ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

N6 Division of Coastal Mgt. Habitat Impact tv+®mpager Sheet
Applicant,
Date: v
Permit #: (u(.,00
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
DISTURB TYPE
Habitat Name Choose One
TOTAL Sq. Ft. FINAL Sq. Ft. TOTAL Feet
(Applied for. (Anticipated final (Applied for.
Disturbance total disturbance. Disturbance
includes any Excludes any total includes
anticipated restoration any anticipated
restoration or and/or temp restoration or
temp impacts) impact amount) temp impacts
FINAL Feet
(Anticipated fina
disturbance.
Excludes any
restoration and/c
temp impact
amount)
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 ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill [I Both C] Other ❑
Dredge ❑ Fill 171 Both 171 Other ❑

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
Mailing Address:
A) Owe
I certify that I have authorized (agent) s 6e- 5no w to act on my
behalf, for the purpose of applying for and obtain
install or construct (activity) boQ-T I lf�
at (my property located at)
This certification is valid thru (date)
/ /1
all CAMA Permits necessary to
Property Owner Signature Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
T-io fit}I(e�
hereby certify that I own property adjacent to _ - - - - - -
o � s
am o Pr e%I Ogwner�
property located at id%I��W �ep `—o-�—�N�a-
Q (Address, Lot, loc RoadLetc)
on -� Y4H T r,AS'i� in _ _ ��4-7 �C- - N.C.
(Waterbody) (CitylTown and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locatio 'Q
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 SEG I IUN
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.)
ip, I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent ropertty Owner Information)
Si 'nature Stoature _
Print or Type Name ( Print or Type Name
1. . t eV A, .... v� �T 71 4:;�' 1 III& . I

AT
vt'
hereby certify that I own properly adjacent to _ _ —K[%a � kv-- ---- ---- $
(N me Pr pe Owner)
property located atr�►'K_�— --
(Address ,Lot, Block, Raq d, etc )
on 4 Lv Pj� Sll�iQJtQ✓ ------ N.C.
(Waterbody) (City/Town and/or County)
The applic t as described to me, as shown below, the development proposed at the above
locati
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 5tG i wry
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set back minimum distance of 15' from my area of riparian access unless waived by
me. (If you w. aive the setback, you must initial the appropriate blank below.)
_ do ish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
�ar� Clew% 5 ---
Print or Type Name t .
Print or Type Name
D A P. %r
Information)
.foo�
It) Q 77