67124d - Dean

1CAMA / ❑ DREDGE & FILL 02✓ �j l:
j% A B
t'EMERAL PERMIT Previous permit #
ew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources 1
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
/� ❑ Rules attached.
t Name (1 Y' ,--'� lti VA Project Location: County V✓\� wiL��
QimStreet Address/ State Road/ Lot #(s)
i
G\ State_�I_ ; =y L-1
( ) r E-Mail Subdivision
ed Agent mubk ZIP
❑ CW �IEW �*TA ❑ ES PTS Phone # ) iver Basin 1/Wv I
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A WA
El
yes / (oJ PNA yes /
Project/ Activity
v\ A i v\ S�zt1
ck) length_
atform(s) J
Platform(s)
ier(s)
ngth
mber
d/ Riprap lei
distance o
uc distance c
cannel
bic s
np —=!.
ie Length
notsure yes
Adj. Wtr. Body nat r
Closest Maj. Wtr. Body
Ym a
(Scale:
cum: n/a in
in
yes no
Attached: y ss no n ,,/,^ K `
ing permit maybe required by: "T V ' ► ! 4 �) \ (�(A� ❑ See note on back regarding River Basin r
Local Planning jurisdiction) — if r x I f I f„ 1 i � - / ,

NC Division of Coastal Mgt. Habitat impact Computer Sheet
Applicant: lam' �(-RV) Permit #, -7 1
Date: o S f a 0
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measuremen
found in your Habitat code sheet.
Habitat 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 fina
disturbance.
Excludes any
restoration andh
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Other
Z (e
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 0

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit. -
Mailing Address:
/7t�%e_n be,-cDT 1 6
Phone Number:
Email Address:
I certify that I have authorized Rw""A'
A ent /Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:b�—
A r<d &A 47� .
at my property located at ) .� � 6—A.,
in �'>,,,,,s�,,'�_County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
���:��_
Signature
Print or Type Name
Title

ADJACENT RIPAR N PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �^
's
Property located at (Name of Propertf Owner)
on _
(Ad - s, LWzzaown
Blocd, a c.)
in
(waterbody) , N.C.
and/or County}
The applicant has described to me, as shown below, the development proposed at the above local
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)
Am;5 6,,41;-F+
Lance I a8 � F Rc�ti: I d t7e�ir.
J-E
�a� gay iaa
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bad
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wai
the setback, you must initial the appropriate blank below.)
I_ I do wish to waive the 15' setback requirement.
1 do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)--1 /,
Sig/inure �• Si ralure
_ i 4!% CnA JI.►tn�n Cy
P aor Type Name nn �T—N�Me
r ,

ADJACENT MPAfi,IM PROPERTy J it` >`�AT T
I t*reby certify that I own property adjacent to _ c a r% a n a V/ 1 r r l y
property toratea atpedL(r 11 A e ► vh 5, , of Pro
q' t? er?
an ��� l ( dress, lot, 1311Road, eta.)
(&!Q fly , N.C.
Waterbody)
(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above locati
I have no objection to this proposal_
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPIMEW
{il 1dWidua4 proposing d-rreiopfnent must ft i in description below or attach a site drawing,
WAIVI-R SECTION
l° ur4erstand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bac
minimum distance of 15' from my area of riparian access unless waived by me_ (if you wish to w.
the se ck, 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.
(Property Owner Information)
�1/�
Sigrrarure
r4I/,r
PrW or Type Name
log 61111 ;4-11 ST
(Adjacent Property Owner Information)
Sign ltr
Print orT, Name
'5J n pr K1i )r� rl Dl'1 t