67235D - Hall

CAMA / ❑ DREDGE & FILL K `0 j„ /
6 !� A B
iENERAL PERMIT Previous permit#
New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
zed by the State of North Carolina, Department of Environment and Natural Resources J =
oastal Reso rces Commission in an area of environmental concern pursuant to 15A NCAC i„J o I '� Go
t El Rules attached.
Name {t Project Location: County
Street Address/ State Road/ Lot #(s)
P VYI c State ZIP ^al a `")
E-Mail Subdivision
:d Agent "�� City'� ZIP Lg
❑ CW /X, A ❑ ES ❑ PTS / kne # (7a�) 3(,3 ~ QL River Basin �Ll/1ti
❑ OEA ❑ HHF fJ IH ❑ UBA ❑ N/A
❑ PWS:
um: n/a yes
yes n
,ttached: 0 no
ig permit may be required by:
_ocal Planning jurisdiction)
Adj. Wtr. t5od IALA
,^� ,A� ll a /rr
Closest Maj. Wtr. Bodyy�1,e-
JIM7 F-' L !! Vh� ❑ See note on back regarding River Basin rL

NC Division of Coastal Mgt. Habitat Impact Corr
Applicant: Z)
Date: 10/ram'J �ot
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
F
(Applied for.
(Anticipated final
(Applied for.
(F
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
di
Habitat Name
Choose One
includes any
Excludes any
total includes
E
anticipated
restoration
any anticipated
re
restoration or
and/or temp
restoration or
to
ternimpacts)
impact amount)
temp impacts
ai
Dredge ❑ Fill ❑ Both ❑ Other IK
C
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date / /"
Name of Property Owner Applying for Permit:
Mailing Address:
J
I certify that I have authorized (agent) C _`� Z'111!�-5 1 _ to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) �c <J
at (my property located at) 4
This certification is valid thru (date)
-� .1" :i
Property Owner Signature C Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Ju f-�l f l... s
(Name 9f Property Owner)
property located at
(Address, Lot,_ tSock, Road, etc.)
on '<!
�► in ' .0 ---, N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
Inc ti
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)
to -A
y
oil
G•' 4.Y4 lkw:� y
_ J
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.
I do not wish to waive the 15' setback requirement.
(Property Ow or Information) (Adjacent Property Owner Information)
Sinature Signature*
d)-) .�1 MBA l� _ j sC?.�!N'7• �-�c�rnt
Print or Tvpe Name

stal Service" U.S. Postal Service"
FIED MAIL° RECEIPT CERTIFIED MAIL`R' RECEIPT
Mail Only Domestic Mail Only
information, visit our website at www.usps.com
.. For delivery information, visit our website at www.usps.com".
11'
15
Certified Mail Fee $3.30
n�
$0e47
47
Postmark
Here
i!$/17/2016
r4ft------ ----------- ----------------
- y.-. -----------------
c�,v� air
I
C3
O
ru
ILn
I
a
#Ln
[] Return Receipt (nard00PY�
Return Receipt leiec mwvici $
CaRRied Mail Restricted Delivery S
[] Adult Signature Required $
Adun signature Restricted OelivarY s _._--------
Postage
■ Complete items 1, 2, and the reverse
■ Print your name andaddress
the t� to You -
so that we on
can recur of the maitpiece,
.
■ Attach this card to the t� ace R�"'�`,
or on the sP
1, Article Add tO'
Apr VN t c
je )1 S
,3.47
elc�q�✓
Postmark
Here
08/17/201 b
VAWWIM"Ise-el Revese tqr instrcti
:--9--' uons
)Yil 201N
c a of
X ,Pd Name)
D. 15 deliv different fTon' Kem 1 r r
It YES, enter jehverY address below'
No
i
nAall EacPreu®