67133D - Gsell

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CAMA / ❑ DREDGE & FILL IZ
G}�ENERAL PERMIT Previous permit #
C Nevv ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
Wized 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
` v -�> R tJ ❑ Rules attached.
it Name L LAB Uri / Project Location: County r "cw'
-- %2—c2 ':2—,r_-�`C" �/1 c" Street Address/ State Road/ Lot #(s) /
kA ! ' nJ state"G ZIP `n SA4 ! 1 2 - 1 Z' C" `-,e �r/47
(OA4 021 E-Mail Subdivision.
zed Agent ip,n Im6- Ci jNjC //V�y-I`GKJ ZIP-Zw
i ElCW Xw )dPTA ❑ ES ❑ PTS Phone # ( )""nn�"—'/ River Basin c� I
❑ OEA �❑ HHF ❑ IH ❑ URA ❑ WA Adj. Wtr. Body !�1
❑ PWS:
!�%' no PNA yes AMD Closest Maj. Wtr. Body if Project/ Activity c . A (� (k-t 7 i'0'
/ (Scale: , !1
ock)length
i I
'latform(s) 5Z401-
/, I
g Platform(s)771
pier(s) �...... _ _._ .._.. L...............
umber \,
ad/ Riprap length
rg distance offshore
iax distance offshore.
-hannel
ubic yards
unp +
i e/ Boatlift ' Z / Z
Buildo3i
ne Length
not sure yes rllfoJ
)rium: n/a yes gn
yes WI i
i
i
Attached: yes — --
ling permit may be required by:� �'✓� I- ❑ See note on back regarding River Basin
a Local Planning jurisdiction)

NC Division of Coa4ta1.M9t. Habitat impaot' COnVuter sheet
Applicant:
Date: r�J
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.
FINA7qF
Feet
for.
Fli
(Ar
(Applied for.
Disturbance.total
(Anticd
disancedis
7(Ae
HabitatName
DISTURB TYPE
Choose One
includes any
anticipated
Excocludes
restoration
.
any anticipated
Ex
re;
restoration or
ternimpacts
and/or temp
impact amount
restoration or
tem irri acts
ter
arr
Other
Dredge ❑ Fill ❑ Both ❑
Dredge ❑ Fill ❑ Both ❑
Other ❑
Dredge ❑ Fill ❑ Both ❑
Other ❑
Dredge ❑ Fill ❑ Both ❑
Other ❑
Dredge ❑ Fill ❑ Both ❑
Other ❑
Dredge. ❑ Fill ❑ Both ❑
Other ❑
":
Dredge ❑ Fill ❑ Both ❑
Other ❑

Q�� ,r
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director
Date 5
Name of Property Owner Applying for Permit:
Mailing Address:
�►S i i�Nl 4 G f� I� � � ��- � I
Dee Freeman, Secretary
I certify that I have authorized (agent) T+—`-- to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) A QaC
at (my property located at) 2t7-) SC✓ IM
This certification is valid thru (date) q — / ' / ✓ 16

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property: � Zo
(Lot or Street #, Street or Road, City &
Agent's Name #: 1�& eb�aL�t-o Aqll� Mailing Address: AW CT) M?<24 K6�
Agent's phone #: N t✓ -%�- 2-�
00 -amc. @—ch
r
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 development
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 beingproposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact Information for DCM offices is
available at httA:IAvww.ncconstalmanagement.net>web/cm/staff-listfna or by calling 1-888.4RCOASr.
No response is considered the same as no obJection If you have been notified by Certified Mail,
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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 requirement.
(Prop'e%y, �?Wn$r-�*Iormation)
Signc?tt14
65a,�-
Print or Type Name
2-12-0 -�tU. L,c: oe Rra
(Riparian Property Owner Information)
i
. -vz-Z
rgnature
Print or Type Name
.t
Mailing Address
Itit.[,�t�n(!^r3w4 alit '26VA1f
Mailing Address
/i/)n / " 1/1// '� �-'t/ / -i

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Lt,4,-pp-� C15c1.L, 's
(Name of Property O ner)
property located at '� 1.?� .5 C%� F-s i{� ixt e f`!� w i N ti T� �( rw-
(Address, Lot, Block, Road, etc.)
on I I`('r i'« ATg5��, in W1Lf,-� It-.! N.C.
(Waterbody) (City own and! r County)
The applicant has described to me, as shown below, the development proposed at the above
location.
t I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must till in description below or attach a site drawing)
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 requirement.
Print or_�y Q N 'Tcr -�J- , y 4 LF
1 �
Mailing f{ddr@ss,
I n.,, Ian _
(Adjacent Property Owner Information)
Sig tire
17rin1 nr T..nn Alomn
ili g ddress //
1 k'R1.' 4"7

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