67184D - Hinson

1CAMA / ❑ DREDGE & FILL
� 1 l 111 l `C
3&ENERAL PERMIT Previou s per mit # A B
New ❑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 I SA NCAC
❑ Rules attache .
t Name__6( VIA-StProject Location: County 4'
I 'A ;�3k � Street Address/ State Road/ Lot #(s)
_6Uk,rJ PStateP�IV
& 0) Lot - 4 3 2 3 E-Mail
ed Agent
❑ CW
❑ OEA
❑ PWS
yes / no
aj'EW lk PTA ❑ ES ❑ PTS
❑ HHF ❑ IH ❑ UBA ❑ N/A
PNA ( yes )/ no
Subdivision
City ZIP,
Phone # ( River Basin
Adj. Wtr. Body �/`� n 6r
Closest Maj. Wtr. Body
Project/ Activity ?r , i L X 1 U
(Scale: i -
:k) length
stform(s) W X , 1
Platform(s) 2 , X
ngth
nber -
i/ Riprap length -'
distance offshore
x distance offshore
cannel a
Ac yards
ip _
se/ Boatlift
Aldozing
Length
rr•
not sure ye no
cum: n/a
kttached
yes no
yes n
yes no
ig permit maybe required by: 7-oINA r k 5 ( Q nA
-ocal Planning jurisdiction)
❑ See note on back regarding River Basin rL

NC, Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: A�"n Date: Permit #:
1
�w
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
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
Habitat Name
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/o
restoration or
and/or temp
restoration or
temp impact
temp impacts)
I impact amount)
impacts)
amount)
Dredge ❑ Fill ❑ Both ❑ Other
I L(1
(P
tjemp
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 [I Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both Q Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to /3e-n A,
(N me of Propefty Owner)
property located at / O J S 2a { Sf v e Q
(Address, Lot, Block Road, a c.)
on _ ��u S C e' -n"- ( in < IJS I Q h , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above loc
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(lne dual proposing development must fi/1 in description below or attach a site drawn
s C P-. <5P c JLO'-et'
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set b
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to
the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
do not wish to waive the 15' setback requirement.
(Property Owner Infonnation)
r
Signature
zs3en A,
_ n sa►�
not or Type Name Pnnt or Type Name
/ O/ s 28 %►� Sf-, r r, i() i,N

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to /&---n %. T o C �
(N�me of Props Owner)
property located at l O j SE 2-a
(Address, Lot, Block Road, etc.)
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above I,
J 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 descripfion below or attach a site drag
S Cal its �'iQ� -sh Q-
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish t,
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 Owner Information) (Adjacent Property Owner Information)
Sigature fi Signature
Pnnt or Type Name f/ Pnnt or Type Name
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