67200D - Evans

7CAMA / ❑ DREDGE & FILL Gam- �l12/1w
" A B
GENERAL PERMI Previous permit#
ANew ❑Modification El Complete Reissue []Partial Reissue Date previous permit issued
xized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
❑ Rules attached.
nt Name �� e �1► ` �i- V Project Location: County �j616(Ad
i' I v `Q y,, oA � yi . Street Address/ State Road`/ ,Lot #(s)
Ilk, �� �-� State, ZIP
(� E-Mai Subdivision
zed Agent City�Vnstl
rk Q ZIP
i ❑ Cw NEW YPTA El ES ❑ PTS Phone # 010) ' _t� River Basin
r
❑ OEA ❑ HHF 'C7 IH ❑ UBA ❑ N/A t—
❑ PWS:
yes / o PNA yes / o�
if Project/ Activity O�, tAV
Adj. vvtr. Body CA "n inat
Closest Maj. Wtr. Body In W
avA
P V \ Vkr 4 U %T � t (A (Scale: � � -
ock) length_
'latform(s) _
g Platform(s)
pier(s)
ength
umber
ad/ Riprap le
jj
,,g distance A
iax distan� c
:hannel 1
Local Planning jurisdiction)
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NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant:%V >
Date: 0 1 MA
Permit #: �7
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
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 final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
VV
Dredge ❑ Fill ❑ Both ❑ Other
G It
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 0 Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

Pat I*Crory
vQvemo,r
R
North Carolina Department of Environment and Natural Resources
N.C. Division of Coastai Management
John E Ski
Secre
AGENT AUTHORIZATION FORM
Date ;� /li-.-/ ;c
Name of Property Owner Applying for Permit. Name of Authorized Agent for this project
Owner's Mailing Address
Email —_
Phone L
J
Agent's Mailing Address.
Tj
- Email
Prone
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for. and obtaining all CAMA Permits necessary to install or construct the following (activity):
For my property located at

(:1rKU1FIED ; — RETURN RECEIPT REQUESTED
DIVISION OF COASTAL: MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property owner. JZI?,,,'S
Address of Property:
(Lot or Street if, Street or Road, City dt County) �i►C _
Applicant's phone g: ,1(0 _ Mailing Address. -
I hereby certify that 1 own property adjacent to the above referenced property. The individual applying for th,
has described to me as shown on the attached drawing the development they are proposing A dcscrintion of
with dimensiorL must be urovided with hie tarter.
have no objections to this proposal. 1 have objections to this proposal.
y If you have objections to what is being
you must notify the Division of Coastal Management ,
in writing within 10 days of receir: of this notice. Correspondence should be mailed to 127 Cardinal Di
Wilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No respoo
considered tie ame as no objection if ou have been notified b Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift roust be set back a minimum dis
15' from my area of riparian access unless waived by me. (if you wish to waive the setback, you must initial
appropriate blank below.)
� ',L. 2S;j�Cdo wish to waive the 15' set back requirement.
1 do not wish to waive the 15' set back requirement.
(Property Owner Information)
Si �ture
Print or Type Name
Mailing Address
I1,..��
City / State I Zip
Telephone Number ��0" " y� � L/V c V
(Riparian Prop Owner Information
r r
�ature
Print or Type Name
c
Mailing Address
City /State /Zip

11612016 10:28 Bid Inspect
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"�A.i n fin. __ l ^r M y(f��� � �(l}n
Y
DWMON OF COASTAL MAriA(;RMNT
ADJACENT RIPARIAN PROPERTY( )R' TMEMMM
Name of Property Owmcr,
AddMW ot?Mperty;
Xir7� MMMM W
1051M,
Appl icant's phm* x: � l �.r ^ c C Maili
4
I boreby oerdfy dw I own p,vporty aOj" to the above refavnrudl MU". The individW a"fyfttg fbr this par*
Ines described to me as shown om tM attached drawing the dcve{oproem ttrey ore Mdlbproposes
i have no objectioct to this proposal. 1 burro objecsiotts to d1fa propaeal.
If Yon bare objectioaa to what is baia ro
in wrtftat witbi% 10 r, a p • 7Oe mast $' tlse I?9v4eio�t o! Coa.ot�al Ma ateat ('DCM)
pt Of" netice- Correspaitdsnco skoakf be malted to 127 Catdbesl Drivel it
w"=btptoa, NC 2840"84-5. DCM rvprmemtatires C&M aiso be maned at (910) 795-72M No tmepoese is
rr h
. .. WAIV7i�R 5>g.CTIaN � .. .
i c urd that a pion. dock, mooring Pibn9k , b04d* &e, or iirt mast be set back a mbtimwm crf l 5' f r*M my area of riper6n accaaa uakes vsaived by tm. (If you wj3h to wslve %he
appropriate bleak Wow.) setback you antral lhgtial the
1 do vrislt to waive the l5' Sat beck r^squiramcat.
I do rsot wish to waive the 15, set back requir'em=L
WroymV VWner Larej mailoa)
amanita
-- �4 ,4 .0-, I n s
Priac or Type Name
�.
Marl ing Addrets
Crty / Stye z4p'
Telephone Ntunbw
X
Pant or Type Name
City /3wo / Zip
Telephone NumW fj / 0 - 5 - l S- ..Z f 7
Dal»
x,.... -- i/ - //

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