66511D - Johnson

�CAMA / ❑I DREDGE & FILL 1�4d-s a� l
,GENERAL PERMIT
4New ❑Modification El Complete Reissue ❑Partial Reissue
- A B
Previous permit #
Date previous permit issued
irized 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 o l '` �0
l/
❑ Rules attached.
it Name v � �� �J �� SG i� Project Location: County f V''�S k,Q (1�
I G Y,A
State ZIP P� i0 i
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t( --1 E-Mail 1p ,,
:ed Agent _Lok 1f`{ Ik`l" , �U ( L-M t" _ V y I AY11t
❑ cW )<EW XrTA An )<PTS
ElOEA ElHHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes //no i PNA yes /
f Project/ Activity ( oV1 7VYV(',"
Eck) lenli
i
atform(s) _ -
tform(s) -
>ier(s)
:ngth
a\mber
d� Riprap length S-0
g distance offshore
ix distance offshore
hannel
bic yard
np
,se/ Boatlift
Street Address/ State Road/ Lot #(s)
� (A v1 ('1 't ' )
Subdivision
City
Phone # (�� b) 3'" River Basin LLAW
Adj. Wtr. BodU , n t
Closest Maj. Wtr. Body
MAW—
M! W�/ANI/M'�I/W'
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(Scale: `" =
❑ See note on back regarding River Basin r
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NC Division of Coastal Mgt. Habitat Impact Coml
Applicant: -T �� J\lj 4,<d
b �j ✓t
Date: o G U ( G
Describe below the /d—
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
FIB
(Applied for.
(Anticipated final
(Applied for.
(Ar
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disl
Habitat Name
Choose One
includes any
Excludes any
total includes
Ex(
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
ten
tem acts
im aacamount)
impact
tem impacts)
am
D (A
Dredge El Fill Both El Other
/irm
( (3v
1 U V
Dredge ❑ Fil(`0 Both ❑ Other ❑
U ICJ
QO 6
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

12 =11- ..
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
AGENT AUTHORIZATION FORM
Date: q� 14 /14,
Name of Property Owner Appi ing for Permit.
rQ lon C>H r")So-y
Owner's Mailing Address —/D_?of &,, c:S ),lc-
i-cilec k VVC- 2261 q
Phone Number 619)_ N MT:
Dee Fre
Sec
Name of Author11iz��gd Agent for this project:
Agent's Mailing Address.
141
Phone Numbed___)
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
(my property located) at %
This certification is valid thru (date)
- P- --- � P-, r'; 2 -
i
Props Owner Signature /Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(Name of Property
c.t7perri tecate.: ;, L.� 1� ' .. t-
tAddress Lot. Block. Road. etc.)
(Waterbody)
?City/Town and/or County)
NC
1 ",e axitcaw "a., !les( rtb(7 .: "'r ,;- _ . , a " tr Owe :.n-erl proposed at the aoove
n
/ ave �o oblect��r � c macs;,
---- wave ebecbc.^s!- t^ 5 p—CPDSa,
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
ram, a )j 5
L
w< A)VER SECTION
L,,idersiand !,)a,. a pre• yJLb , ::,0'" ; ?Pa' ;"a•akw!ater b0afM0tj,; t i.M f1r gra;r
must be set bac- :a mtn,•r;;rn rr rivarar, access ,,mess waived by
'1B If yUi Wrsh !O w e !rle se'ra--R f. ,. muSt Wit',"' _` dUli!oCh;ttf Mani De:ow
wrSh to w&Ve "'r- Setback (eq,cremerr
(Property Owner Information) ( nt Property Owner Information)
1�Ilgr i-./ 7�1,.,t;W J0 t
2
_--

N]
I hereby certify that I own property adjacent to k2i.L s
am of Property Own
property located at 3 L
/� (Address, Lot, Block, Road, c.)
on --� r,� in 5��.� ,:.erg i 1.e&, A 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
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)
r
W�2
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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 you wish to waive 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)
ignat ure Signature * '�
Print or Type Name Print or Type lVame
/ 90 7 Xt;-,'O�