67216D - Fowler

ILAMA / ❑ DREDGE & FILL
GENERAL PERMIT Previous permit# A B
!New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
•ized by the State of North Carolina, Department of Environment and Natural Resources �\� ' ' WO
q
;oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC ��,,JJ
(4 ..0 Rules ttached.
t Name ! 1\ �MyC.• Project Location: County
Street Address/ State Road/ Lot #(s)
-7.1 ['-State Nt- ZIPS%
U 02Z .. `= �� E-Mail J Subdivision
ed Agent �+�y I (7 N N�� City'GL*—F e_-{T 4 ZIP
❑ CW `F3 W "TA )as ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
yes PNA 4:jeDs no
Activity
ck) length k1 Y ?jC
itform(s)
PlatNrn(s)
ier(s) 4
ngth
nber
4prap length
distance offshore
x distance offshore
cannel
nP .
se/
e Length
not sure yes o — —
ium: n/a yes no
yes no
kttached:
ng permit may be required by: `
Local Planning Jurisdiction)
Phone # ( ) River Basin C�
Adj. Wtr. Body %IVA Tom;
Closest Maj. Wtr. Body 5 j U yle C,
(Scale: (ram
❑ See note on back regarding River Basin r

NC perrISion of Coastal .Mgt. Habitat impact- Computer Sheet
Applicant:
Date:
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
F11
(Applied for.
Disturbance.total
(Anticipated final
disturbance.
(Applied for.
Disturbance
(A�
dis
Habitat Name
DISTURB TYPE
Choose One
includes any
anticipated
Excludes any
restoration
total includes.
any anticipated
Ex
re;
restoration or
temp impacts) acts)
and/or temp
im act amount
restoration or
temp ini acts
ter
arr
Other
I 6
w 1
Vv•
Dredge El ❑ Both ❑
L�
Dredge [❑ Fill ❑ Both . ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge. ❑.
Fill ❑ :
Both ❑
Other ❑
..
Dredge ElFill
❑
Both ❑
Other ❑'
t ,rt

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATIOIPI
Name of Property Owner Requesting Permit: 1Z )I11IA­,rI J , 115;li-'lcr
Mailing Address: 4-A/�ih��� ��%/�sa•r�
Phone Number: ?'/0
Email Address:
I certify that I have authorized ;
Ag t / Contractor _
to art on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:« g
at my property located at
in — �eYI �e/'" County.
l furthermore certify that l am authorized to grant, and do in fact grant pet -mission to
Division of Coastal Management staff, the Local Permit Officer and their agerr`s to enter
on the aforementioned lands in connection with evaluating information relat9d to this
permit application.
Property Owner
M wj/I Wr V) OWE M
V j 7
Print or Type Name
� W 17 arL
T:II_

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Se % �Is
(Na f P ope Owner)_
property located at
ddress, Lot, Block, oad, et .)
on Cz in C , N.C.
(W terbody) (City/Town a d/or County)
The applicant has described to me, as shown below, the development proposed at the above locatic
_4,,Z I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPME A
(Individual proposing development must rill in description below or attach ar site drawing)
WAIVER SECTION
I understan h4apier, doc ooring pilings, breakwater, boathouse, lift, or groin r,rust be set back
minimum sta15' from area of riparian access unless waived by me. (If you wish to wai,
the setbac yot initial t ppropriate blank below.)
774 1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Pro )erty Owner Informati n) (Adjacent Property r Information)
i ture Si ature /
J - 7-01w
Print or Typ Name Print or Type ame
�7`.� �` /LS f '0 A, Ali-

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER F0RM
Name of Property Owner: k111114t47
Address of Property: L oT 4R W rk'ns an 1 a fx17—e0a./
(Lot or Street #, Street or Road, City & County)
Agent's Name #: MailingAddress:
Agent's phone * q10 3 � � 7� lf� />l�; . z. • C _ � s
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the dews lopment
they are proposing. A description or drawing, with dimensions, must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Manageme e t (DCM) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive &t,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. No re:'-ponse is
considered the same as no objection if you have been notified by Certified Mail. .�
WAIVER SECTION
I understand that a pier, doc , oonng . ' s, breakwater, boathouse, lift, or groin muse be set
back a minimum distance f 15' from my a f riparian access unless waived by me. (11 you
wish to waive the setbac ,you must initial t appropriate blank below.)
I do wish to tback requirement.
I do not wish to waive the 15' setback requirement.
(Properth, O�wne In rmation)
Signature A)I/I►4,n J
Print or Type Name
4,A.1 )17-kin5oy
Mailina Address
Signature
d Ck
Print or Tva Name
Mailing Address
n r Inforri ation)
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