66588D - Henderson

CAMA / ❑ DREDGE & FILL K " sr/* I
S A B
�ENERAL PERMIT Previouspermit#
ew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources ©1 H � c h
oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC ❑ Rules attached.
Name "y' V'\ (A'
i State NL ZIP I Gl
(Ell l E-Mail
ed Agent Ay 6w � G � �
❑ CWEW LTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UIBA ❑ N/A
❑ PWS:
yes / Co PNA yes /
angth
amber
id/ Riprap length
g distance offsbk
ax distance gfish
hannel r
jbic
Boatlift
Project Location: County 12 VVVA 5 VV1 1—
Street Address/ State Road/ Lot #(s)
Subdivision
City e, ZIP i l
Phone # ) 5-J6 d 5 River Basin LAW
Adj. Wtr. Body Gr N (A (nat
Closest Maj. Wtr. BodyI w

NC Division of Coastal Mgt. Habitat Impact Com
Applicant: SV b1-T,
Date:
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
FII
(Applied for.
(Anticipated final
(Applied for.
(Ai
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
dis
Habitat Name
Choose One
includes any
Excludes any
total includes
Ex
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
ter
temp impacts)
impactamount)
ternimpacts
arr
r /
Q W
Dredge ❑ Fill ❑ Both ❑ Other
�6
0
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

1/06/2016 14:37
9197826598
HENDERSON f
PAGE 01/

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to �U1,� 'g, t lj��RSL�I 's
tNnmc of Prnncrty inuwner%
property located at IDS q
(Addres's, Lot, Block, Road, etc.)
on CANRI, G in NdDEN FAA .14 N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
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)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat rarnp, 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 yqu wish to waive the setback, you must initial the appropriate blank below.)
/Gj
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Si ature
Print 6r Type Name
AA„I,,,.,
-- —,
-�gnature� r
Print or T* � e N e
----� .rC —\-;, ??C

34/06/2016 14:37 9197826598 HENDERSON PAGE 01
ADJACENT RIPARIAN PROPERTY QWN R S TEMENT
i herebyce ' " at i own property adjacent to s
+hame of Property owner)
property located at —
(Addrdss, Lot,. 13loc lc, Road, etc.)
on in N.C.
(Waterbody) (CityrCown andlor County)
The applicant has described to rne, as shown below, the development proposed at the above
lac �
i have no abjection to this proposal.
l 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)
WAIVER SECTION
understand that a pier, dock. mooring pilings, boa`: ramp, breakwater, boathouse, lift. or groin
must be set back a minimum distance of 15` from my area of riparian access unless waived Oy
me (if you wish to waive the setback, you must inttlal the appropriate blank below,)
do wish to waive the 151 setback requirement.
do not wish to waive the 15' setback requirement,
(Adjacent Property Owner Information)
Si � re Si munere
P.nnt r i yos Na. e Frirt or ; ype�! am&
' il''1Q Address. ., , ,, l�Aerling Adaress ,r"2... r

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