67129D - Julian

4.
XE/
❑DREDGE &FILL Nu RAL PERMIT Previous permit # A B� "
New ❑Modification ❑Complete Reissue ❑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 I SA NCAC
4 Rules attached.
t Name d J V Y1 Project Location: County
.� 6f L/V Street Address/ State Road/ Lot #(s)
1A14 i'' S GY ✓ 1 State �f - zip z S
s
E-Mail Subdivision
ed Agent T ( lVe4V G City zip 2 -4
❑ CW )&XW 5dwTA ❑ ES ❑ PTS Phone # ( ) River Basin
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ N/A
El PWS: Adj. Wtr. Body; "7i/rl:'y✓/G4- /g'4 t- (na /i
yes i PNA es no
Closest Maj. Wtr. Body='7�%j'
' Project/ Activity jM 11 A 1 ` L12 oc(
ck) length_
atform(s) _
Platform(s)
nber
i/ Riprap length_
distance offshore
x distance offshoh
cannel
tic yards \
ip
! o'B ft K
ill`ing
_T
Length
not sure yes no
cum: n/a yes
yes So
atached: no
ig permit may be required by:
-ocal Planning jurisdiction)
(Scale: ( (L-
❑ See note on back regarding River Basin n

NC Division of Coastal .Mgt. H2bltat impact Computer Sheet
Applicant .� d r✓ J t''�'�
Date: — r6
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
for.
FII
(Ai
(Applied for.
(Anticipated final
disturbance.
(Applied
Disturbance
dis
Habitat Name
DISTURB TYPE
Choose One
includes
includes any
anticipated
Excludes any
restoration
total includes
any anticipated
Ex
re:
restoration or
tempimpaccctts
and/or temp
impact amount
restoration or
tem im acts
ter
an
Other
a�t%
Dredge ❑ Fill ❑ Both ❑ .
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge[]. Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

X
N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date � � k�— ( `Fe
Name of Property Owner Applying for.Permit:
i i_ --\ -/7. n-- _ ,
Mailing Address:
I certify that I have authorized (agent) to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) r �, 1196AII) 1,2 ,
at (my property located at) A 13 c� t
This certification is valid thru (date) a-0 l 3
Property Owner Signature
Date

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:
Ur
(Lot or Street #, Street or Road, City & County)
Applicant phone#: - OD6 (LAAf
R t D 3:).-) 34 � J
-
0,tv� 64.:� u, �
Mailing Address: 0 5A VI W i k,
ROME
I hereby certify that I own property adjacent to the above referenced property. T;.9 individual
applying for this ermit has described to me as shown on the attached drawing the development
they are prop ing. A description or drawing, with dimensions, must be provided with this letter.
have no objections to this proposal. I have objections to this proposal.
If you ve objections to what is being proposed, you must notify the Division of Coasta: Management
jDCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at www.nccoastalmangement.net/contact dcm.htm or by calling 1-888-4RCOAST. No
response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier ock, mooring pilings, breakwater, boathouse, or lift must be set back a
minimum distan 15' from my area of riparian access unless waived by me. (If you wish to
waive the s ack, 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)
ignature "
not or Type Name
(Riparian Property O orm ion)
Signature'.
Ph-1, Y-s
Print or TypgWame
AAall;n A.iri o
'i 1 1 1-o-�

7LOZ/g Pasinaa
CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or Street #, Street or Road, City & County)
Applicant phone #: AWf ✓b+' V GoAk-ai—Mailing Address: oa 5 )- `z � d'ou"'`
I hereby certify that I own property adjacent to the above referenced property. T le individual
applying for this permit has described to me as shown -on the attached_ drawing the development
they are proposing. A description or drawing, with dimensions, must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
If yoItc objections to what is being proposed, you must notify the Division of Coasta: Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at www.nccoastalmangement.neticontact dcm.htm or by calling 1-888-4RCOAST. No
response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be set back a
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to
waive he 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)
ignature
not or Type Name
X 7 /ter
Mailinq Address
(Riparicin Property Owner Information)
14 -
Si, natu
o
Print or Type Name
bfte-
Mailing Address r — _

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