66510D - Holland

:FAMAi; / ❑ DREDGE & FILL A B
GENERAL PERMIT l Previous permit #
New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued_
)rized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC 07
i ❑ Rules attached.
it Name /??U� ��\04 Project Location: County t MN5 V" ( I�
PQ l> 6 X to I Street Address/ State Road/ Lot #(s)
bmt h State N( ZIP g -
(`v-Mail Subdivision �!�i/V� +Y,- j ,/
zed Agent �u�� I I�wS — (��cl{� a City (Xecy) S-S�t_ (�t�( �1 zip 1.`6
1 ❑ CW [IEW OOTA ❑ ES ❑ PTS Phone # (AID ) - IuH 3 ' �� �, River Basin L 1i1 Y
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A C a Y\ a
Adj. Wtr. Body nat
❑ PWS:
yes / no PNA yes / Closest Maj. Wtr. Body W
if Project/ Activity on
Scale:
ock) length ��, x
'latform(s)—
g Platforms) \
ength
umber
ad/ Riprap Ii
eg distance
iax distance
hannel A
ibic
imp
Room
Hw�1 �®
i �.�gi�l'is 1 illy
ne LengRth1_
�r l��■�Nrw��l��l��� �����not sure yes 410
)rium: n/a yes no f• �1lr.rIrr J-­-J-­-�j.� { 'J} �v
11
yes no ( w 1� _ t f , �" n . I I
Attached: yes no
Jing permit may be required by: 1 Owh T OUWA IS` t 9(a(•k ❑ See note on back regarding River Basin
Local Planning jurisdiction) ,1 %' , ,

' NC Division of Coastal Mgt. Habitat Impact Con
Applicant: M 0 - hao\S
Date: D t/ 1 5/ 1
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. (,
DISTURB TYPE
Disturbance total
disturbance.
Disturbance d
Habitat Name
Choose One
includes any
Excludes any
total includes E
anticipated
restoration
any anticipated r
restoration or
and/or temp
restoration or t
ternimpacts)
impact amount)
ternimpacts) a
DDredge
❑
Fill ❑
Both ❑
Other
3 �—
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑

CDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
Dee Freen
Segel
AGENT AUTHORIZATION FORM
Date: r,
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
Owner's Mailing Address:
e,o, 6.x G►�,�
ft (�0 % �L= Beach OV
PhoneNumber(
Agent's Mailing Address:
Phone Number f 9&U) z/y3 — F
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAlAA Permits
to inciarl nr rnnctn in tho WInwinn l ;rtivitvl-
This certification is valid thru (date) 11
3 � o
Proneperty Owign re Date

2016 12:40AM HP Fax
page 1
DIVISION OF COASTAL MANAGEMENT
,ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIOIWWAIVER FORM
Name of Property Owner;
Address of Property. -�4 `7 , ..� j
(Lot or Street #, Street or KOM. Lary a County)
Agent's Name #: 4x.,,e %�,�. ZdS q �3 "ling Address: 5�o 7�s lr^
OF
Agent's phone #: ���-� `� I �f�t� n! T—:t
I hereby certify that I own property adjacent to the above referenced property. The indhridu;
applying for this permit has described to me as shown on the attached dro wing_the developrnw
they are proposing. A dee ApWn or dwith dimes, must be orovOO with this fitter.
► �"`- 1 have no objections to this proposal. I have obicclions to this proposal,
11 yet, haw oWectlom to what is belly pnVosud, you,nust nod y me Gtvh*m of CassW Ma»ogamant {1)t,iQ t
mOng v*Wn 10 days of nscefpt of this nodes. Coempparder#ce shot,ld bo maAed to 12T Cara! DO" E6rl
MUrPtnytn, NC, 28404M. DCA! repraaentstivas con slta be contacted at WO) 796-7215..No response i
considered ttte same as no objection # you have bmm no/ttieQ by CertNied Matt.
WAIVER SECTION
I undendamd that a pier. dock, rr►ooring p , breakwater, boaihouse, lift, or groin must be set
bade a minimum distanoe of 15' from my area of riparian mess unless waived by me. (if you
wish to waive the setback. you mast loltlal the appropriate blank below.)
Ntt�&k ;�P irVJ I do wish to waive the 15' setback requirement.
do not wish to waive the 15' setback requirement.
(property Own 10 ti ) e
(UJ Signature
JAd}acent Property Owner Informationj
XS
8t norwe

2016 12:40AM HP Fax
page 2
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOT`)FICATIONMAIVER FORM
Name Of Property Owner
�f
Address Of Prop" ` &w � W i'm____
(Lot or 5!reet 0 5trM or KO M. GRY a County)
Agent's Name # /p�.. t',,..IAL bq
Agent's phone k
Malang Address
I hereby certify that I own pfoperty adjacent to the above referenc;od ptopetty. The indivW
a for this permit has described to me as shown on the attached draWng.the developm
they are proposing. A descrkkon or drawft with d►mensiotts_ Matbe nrovicM Yv-fth this iette
I havc no objections to this pruposa'.. _ _ _ I have obj"tion5 to this proposal.
' If rou haw ot4whons to what is b0 tp Pvoposed, Your e+ur�r rwtPa<j'tAa D�frlaaton o/ Coasl� D t �
++r► dhg wrthM f0 days of rrceipt a4 this norfico. Correspondence should bo malted to 127 CangnO 0#fV4 I
tA+tt nkWm, NC, 284MI645. OCM retseaenradves crn afro be conleCted at [phone]. Me rtitpons
conskkned tha sam* as rro *Wwttwr N jnou Rare boon nodfiad by Cert*ed rusts.
WWANER SECTION
I undwstand that a pier. dock, mooring pilings, breakwater, boathouse, lift, or groin trot be !N
bade a minimum distance of 15, from my area of riparian access unless waived by rne. (If you
wish to waive the setback. you must inthe apprognate blank below )
I do wish to waive Me 15' Setback requirement
1 ' setback re xArermnt.
1 do not wtsh to waive the 5 q
(Property Own �Ijo ti } (Adja t Property Owtt r Irt,Cbrmt Aatlo
USrg»oture tlure