66300D - Clark

I CAMA / L DREDGE & FILL
+ A B
3ENERAL PERMIT 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
^ / ❑ Rujes attache
t Na4 e-e T /�q ` Project Location: County `�� �Ty.. �� 7J
Street Address/ State Road/ Lot #(s)
1
.rr -�' at dc�, staters P 1 t/ t{> i " . , '` .. z.
(l tp) - i F�-Mail Subdivi�ion n
:ed Agent
fi" City it d E� - ZIP
❑ CVl/ '<iEW ',KPTA XES ❑ PTS Phone # t - River Basin
❑ OFA ❑ HHF ❑ IH ❑ UBA ❑ WA
Adj. Wtr. Body 1"4El PWS:
f fiat
yes rno ) PNA yes /" no�
Closest Maj. Wtr. Body
Project/ Activity jL
ck)len$th
atform(s) i
Platform(s) t'
ier(s),
ngth
mber
-a.
d/ Riprap length j
distance offshore
a distance offshore
cannel
;i yards
ip
s Boat ift 1(12,
ulldozing
Aoi
.............
Length
not sure yes `no
cum: n/a yes no
yes no
kttached: y� no
ng permit may be required by:
Local Planning jurisdiction)
(Scale: //Z
❑ See note on back regarding River Basin n

NC Division of Coastal :Mqt. Habitat lrnpact' COMPutelr WOO
p
licant; C /a
ate: D
escribe below the HABITAT disturbances for the application.: 1
II values should match the name, and units of measurement found in your Habitat code sheet.
FINALS Ft TOT�FA
TOTAL Sq. Ft.
(Applied for.
q
(Anticipated final
(Applied for.
ted fin<
Disturbance.total
disturbance.
Disturbance
disturbance.
DISTURB TYPE
includes any
Excludes any
total includes .
Excludes any
and)
abitat (dame
Choose One
anticipated
restoration
any anticipated
restoration
temp impact
restoration or
temp impacts
and/or temp
impact amount
restoration or
temp im acts
amount
Dredge ❑
Fill ❑
Both ❑
Other
Dredge ❑
Fill ❑
Both.
Other ❑
Dredge ❑
FillK
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑.
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other 0

-�►''iAI
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date T�?'I 15 ` ?A 110
Name of Property Owner Applying for Permit:
Mailing Address:
01� C) M Eevn 'R.010tt� .
YrytM P S —.% 1-4- L - * --- 3
I certify that 1 have authorized (agent) 9-C, ( �, (Cw,.O� to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at) C 70 /P?a I" d n7
This certification is valid thru (date) l Z - 3 (- ke

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to �e, 1��d /a4� 's
(Name of troperty Owner)
property located at
7e 1117A&z
(Lot, Block, Roid, etc.)
on f �i 60 , in Ae'i- r , N.0
(Waterbody) (Town and/or County)
Applicant's phone #: ` X 3& 7 '-2r551 Mailing Address:
Ie,.V, - ftr�
42�Z 17� 11r C t-
yc- Za'Y'4
He has described to me, as shown below, the development he is proposing at that location, and,
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
----- I do wish to waive that setback requirement.
---------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
-- ----------------------------------------------------------------------------------------------------------------
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
Mailing Address U Signatui

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGS/BOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to rr�el�,ee
(Name of Pro arh' Owner)
P
property Iodated at 11 7e
(Lot, Block, Roid, etc.)
on ��i G�1 , in A&LA r
(Waterbody) (Town and/or County)
Applicant's phone #: f JV 3& -7 -,2 r5-1
I
Mailing Address:
t4f Svc- Z�
He has described to me, as shown below, the development he is proposing at that location, ;
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boatf
must be set back a minimum distance of fifteen feet (15') from my area of riparian access w
waived by me. (If you wish to waive the setback, you must initial the appropriate blan
below.)
I do not wish to waive
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
(Riparian Property Owner Informatioi
Mailing Address
Sig]

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