67289D - Huntley

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NC Division of Coastal Mgt. Habitat Impact Com
Applicant:l'V- ^ �.
Date:
Describe below the HABITATIsLiagnces 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
FI
(Applied for.
(Anticipated final
(Applied for.
(A
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
di:
Habitat Name
Choose One
includes any
Excludes any
total includes
Ea
anticipated
restoration
any anticipated
re,
restoration or
and/or temp
restoration or
tei
temp impacts)
im act amount
temp impacts
an
AWDredge
❑ Fill ❑ Both ❑ Other
a
✓�
Dredge ❑ Fill ❑ Both ❑ Other
I t I 1
1
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
I � J

ant Proccessing Confirmation
eceived 10/21/2016
=rom (Name) Justin R. Huntley
34 Permit Holder Justin Huntley
Number 2164
amount $200.00
e Permits No
Ainor
Number/Comments GP 67289D
t or Refund/Reallocated TM/2857D

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Just in 1-1u.nt l evi I
(Name of Property Owner)
property located at Lots i 12 and 13 Block 93-Y Lor. Beach on West Pelic.
(Address, Lot, Block, Road, etc.)
on Montgomery Slough , in Ca p T-� Lan.:: , N.C.
(Waterbody) (CitylTown and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location. ,
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
Drawings were provided.
No part of the proposed structures will encroach into the 15'
Riparian Corridor
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.)
4A1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (A - c t Property Owner I rryat r
Signature Signature
Dana Lutheran for _sti.n Huntley
Print or Type Name
5315 S Colleae Rd. u E
Print or Type Name

® Complete ite72,,,andAlso complete
item 4 if Resis desired.
II'l'
RSC
1, Article Addressed to� �C WIL
e-y
A. Si nature ❑ Agent
/i ®❑ Addressee -
� w C. Date of Delivery
B. Received by ( Printed Name)
D. Is delivery address different from item 1? ❑ Yes
vVtYES, enter delivery address below:' ❑ No
IGTON, NC ;��
(3
Ij
g, Service Type Express Mail
El Certified Mall 0 etturn Receipt for Merchandls
❑ Registered [3 C,O.D.
❑ Insured Mall Yes
4. Restricted Delivery? (Extra Fee)
7011 1570 0001 5643 7763 - -
1 2. Article Number __- __ 102595-02-M-1
(Transfer from service label) Domestic Return Receipt
PS Form 3811, February, 2004

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