66673D - Grove

�CAMA / ❑ DREDGE & FILL �� I A B
x NERAL PERMIT (SJ �(l l I Previous permit #
Jew []Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
ized 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��,� t� • �i l✓
❑ Rules attach
Name Project Location: County is &M
V,A VJ t> ftit C T . Street Address/ State Road/ Lot #(s)
xy,( `�v �� State S c ZIP 1 j d (.� U !, �" 4` 5�
(� 4 _11S E-Mail Subdivision
:dAgent ',AV1Q. k LIA5 '1`r' �QC/ity� V�� ZIP
❑ CW �K'Ew *A ❑ ES ElPTS F'hon # (t) 443—'A O ` lcf River Basin � 1
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body nat
❑ PWS:
fes / PNA yes / Closest Maj. Wtr. Body INS
Project/ Activity
r i\
A) length
tform(s)
Natform(s)
er(s)
igth
nber
I/ Riprap len h
distance offshore
Length
not sure
kttached:
(Scale:
ig permit may be required by: 76 "" n 6T j (/{n St atl�� " ' ❑ See note on back regarding River Basin n
-oval Planning jurisdiction) n I _ _ 11 . j 1 . 'S ; .

,MC Division of Coastal Mgt, Habitat Impact Computer Sheet
Applicant: M'Z W
Date: G / a-3 /a.o ( 4
Permit #:
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
cts
FINAL feet
(Anticipated fina
disturbance.
Excludes any
restoration and/c
temp impact
amount)
W
Dredge ❑ Fill ❑ Both ❑ Other 1W
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 ❑

I
NCDENR
North Carolina Departs -lent of Environment and Natural Resources
Dtvtsion of Coastal Management
Beverly Eaves Perdue James H. Gregson
Govemor Director
Dee Free
Seu+
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit Name of Authoriis/gd Agent for this profect
/y/G/tr�t�L �, 63�A/r, a - �tl�. - - -
Owner's Mailing Address
z 47i�
Phone Number
7a,/_ 4w O/ Y 9 au-
Agent's Mailing Address
-- J11,L '
Phone Number (yk") NY3 -
1 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)
' -Pk, rl-&t7 ✓,dorms / A /-/ AVirt/ ltt0sa..y4,V All"fe !jq 2-
(my property located) at 4116 60h'o S fko-k�'7- �tr N&Gf
?11s certification is valid thru (date)
Property fwmtr nature Date

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAIVER FORM
/= 7
Name of Property owner % i` c' - < - -e
Address of Property � P P
,'Lot c, S^eet A Street or moan L ity a County) c
Agent's Name # z - /g /1 , Mailing Address l G % t r "
Agent's Phone # IIL7-- y q.? Ll2 -
I hereby certify that I own property ad)aceni 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 des: -notion or drawing with d►mensiOnS must be Drovided with this letter
i
u, �� I hay r iio objections to this pruposal. I have objections to this proposal.
I II you have objections to what is being proposed, you must notify rho Division of Coastal Management (DCbt) it
writing within 10 days of receipt of this notice. Correspondence should be mailed to 117 Cardinal Drive Ert.
K41mington, NC, 28405-3845. DCM representatives can also be contacted at [phone] No response is
considered the some as no objection it vou have been notified by Certified Mail
WAIVER SECTION
I understand that a pier. dock, mooring pilings, 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 Manic below )
N'`� I do wish to waive the 15' setback requirement
wep I do not wish to waive the 15' setback requirement
(Property Ownor Injorr18tion)
JSignalu"
(Adjacont Proporty Owner Information)
X --
tKnul ure
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