67147D - Hartley

XPAMA / ❑ DREDGE & FILL �� " ``;`
'ENERAL PERMIT / Previous permit #
`Xlew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources 1
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC 0, I f1 06,
❑ Rules attached.
it Name — G t, (-� Project Location: County ► waa
Street Address/ State,Road/ Lot # )
i Y1 VV` State ZIP Q V' 'h �
�q E-Mail —�' Subdivision
ted Agent 9 y� \H, ((y t;� I 1 City � 14w 6Ca ( ZIP
❑ CW ' W A ❑ ES ❑ �PTS Phone # River Basin LAM
❑ OEA El ' ❑ IH ❑ USA ❑ N/A ( )
C
❑ PWS:
yes / no PNA yes /
f Project/ Activity
ck) length_
atform(s) _
Platform(s)
ngth _
tuber
d/ Riprap Ii
distance i
uc distance
cannel
)ic yards
np
se/r
Adj. vvtr. Body ui- V I (A (nat /i
Closest Maj. Wtr. Body11 �MA)
a
= l mm�� m irm Em' 11
■� ■�■!�G isV■MEMO
■ NINEsit
MIN
(Scale: I " y K
❑ See note on back regarding River Basin rt

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: V2" �— [- .
Date: D <K It S Ab l )
Permit #; V7, �,-7-k
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measuremew
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
temp impacts)
FINAL Feet
(Anticipated fina
disturbance.
Excludes any
restoration andh
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Fill ❑ Both ❑ Other ❑
Tredge
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 ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit C
1-4a,-41 e,4
Mailing Address, -Y �) (-)
A/c 7 3 z(]
Phone Number:
Email Address:
I certify that I have authorized J A IS Re,-,od.- r,
ZAgent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development
at my property located at 'I) C,
in County,
i furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application,
Property Owner Information:
Sighature
. ................
Print or Type Name
Title

L OR
1 1 1 •� S . 1 1 1 •.
The nt has describrad to me, as shown below, the deveWnent proposed at the above local
1 have no objection to ttis proposal.
I have objections tD this proposal.
DESCRIPTION AMOM DRAWING OF PROPOSED DEVELOPIWENT
(k+Mcbaf pry Jng d artist of Nn dascdp0on bebw or aftch a sft dig
1116 1 � -aD I I;-� ,) I I �'�
3• Gnc
WAVER SECTION
I understand that a pier. dodo, mooring pifings, breaicwa r, boatrrouse, K or groin must be set be
minimum distance of 15 from my area at riparian access unless waived by me. (rf you wish to w
the setback, you must inif>sd the approprMe bkknk below-)
i oo wish to waive the 15' semadc rewliv ent
I do not wish to waive the 16 Setback requirement
(Pn"rty Owner
Si

AD iACENT RIP/�tttAm aROPERTY aMiINER STATFtiENT
I hereby certify that I own property adjacent to )I .&
Property looted at l c r '� (Name of P Owner]
( mess, Lot. Block, Road, etc.)
on C'�„a� in " lu
(WaWrbody) N.C.
(City/Town and/or County)
The applicant has described to me, as shown below, the devefopment proposed at the above locatioi
.� I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(IndFvidual propo:'fng VOA)
P'MW w&W fiN In doscdpdon below oraltsch a site dnrwinW
WAIVER SECTION
i understand that a pier, dock, mooring pilings, bnw kwater, boathouse, lift, or groin must be set back
minimum distance of IF from my area of riparian access unless waived by me. (if you wish to wan
the setback, you must initial the appropriate blank below.)
I do wish to waive the IF setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjaasnt Property Infonrwiion)
z4j -ee
signatur { .� S1 twe.�'�
Print orType Afame
r or T } 51 4 )
Madina Addraim Aj**m&e .,