66567D - Cox

�CAMA / ❑ DREDGE & FILL r /
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'permit
'KNERAL PERMIT
Previous
New ❑Modification El 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 I SA NCAC
n
t'Name CO\Vi C (Q
❑ Rules attached.
Project Location: County t S�/►���
Street Address/ State Road/ Lot #(s)
SCE State�CIF��
E-Mail
Subdivision---
ed Agent �- �Ae(A
ZIP L� I
❑ CW ElEW El PTA /KES �I PTS
nCity
/ ,Phone # D River Basin UW
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ N/A
Adj. Wtr. Body (nab
❑ PS:
W
yy
yes / PNA yes / no
Closest Maj. Wtr. Body
Sic yar s
np
e/ Boatlift
ulldozing
S%V e
-L,
r
e Length b
not sure yes
lum: n/a yes
yes
o
Attached: yes
ng permit may be required by:
Local Planning jurisdiction)
❑ See note on back regarding River Basin r

NC Division of Coastal Mgt. Habitat Impact Com
Applicant: �O nh� ( coy
Date: 6
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
FII
(Applied for.
(Anticipated final
(Applied for.
(Ai
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
dis
Habitat Name
Choose One
includes any
Excludes any
total includes
Ex
anticipated
restoration
any anticipated
re<
restoration or
and/or temp
restoration or
ter
ternimpacts)
impact amount)
ternimpacts)
arc
1
1
Dredge ❑ Fill)6 Both ❑ Other ❑
000
0 0 0
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

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I hereby certify that I own propert adjacent to
property located at 2,11,
(Name of Property Owner)
(Address Lot, bi c oaa et
onAq � - in i ��L , N.C.
(V aterbody) (City/Town 7ndior County)
:The app ant has described to me, as shown below, the development proposed at the above
cato .
I have no objection to this proposal. Ck
I have objections to this proposat(.-
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
v_tS-ta 1 Ll
Cox
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 requir it.
(Pr y Owner Information) djac
,,y - ��
nt Pr erty n tion
Print or e ame/
Mailing Address
Natuxe
f�
Primer Type
City/State2ip '� City/sta

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 2t- - C 1"61.r s
(Name of Property Owner)
property located at Rlaoi -�
(Address, Lot, to k Road,
on Ala in ��^ �t� N.C.
�(Waterbody) (City/Town and/or County)
The ap Ii shown below, the development proposed at the above
on. q
�
I have no objection to 7thisproposa . &0�J&Uga-jI have objections to thoposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development t filEi escription below or attach a site drawing)
e Iox-i
c" ar
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.
V I do not wish to waive the 15' setback re9�ve
(2Zy.
Owner Information)
y
ace t Property Owner -information)
77
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