66317D - Jenkins

J CAMA '/ ❑ DREDGE & FILL ( A B
BEN ERAL PERMIT Previous permit #
New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources
.oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC "
❑ Rules attached.
t Names i 7jA r ail Project Location: County �� j,•
,�C. -� C.• i,j State ki L— mp 5
JMY54-i= A:l39 E-Mail
ed Agent N /4'---
❑ cW)ftw)rrTA ❑ ES ❑ PTS
❑ OEA ❑ HHF L IH ❑ UBA ❑ N/A
❑ PWS:
Street Address/ State Road/ Lot #(s)
Subdivision
City - t �' ZIP, RA
Phone # River Basin
Adj. Wtr. Body `, " ('1VA--0 GN4A'L AVi
yes / no PNA yes /b� Closest Maj. Wtr. Body �ti'Vk1�v�j
' Project/ Activity(
ck) length_
►tform(s) _
Platform(s)
ngth
nber
i/ Riprap length
I distance offshore
x distance offshore
cannel
sic yards
ip
Length Yu
not sure yes
cum: n/a yes sp
yes
lttached: yes IS
(Scale: J i /,
ig permit may be required by:
-ocal Planning jurisdiction)
❑ See note on back regarding River Basin n

NC Division of Coastal .Mgt. Habitat lrnpact Computer Sheet
plicant:
scribe below the HABITAT disturbances for the application.
I values should match the name, and units of measurement found in your Habitat code sheet.
-IFTOTAL
Sq. Ft.
for.
FINAL Sq. Ft.
(Anticipated final
TOTAL Feet
(Applied for.
FINAL Feet
(Anticipated fins
DISTURB TYPE
(Applied
Disturbance total
disturbance.
Excludes any
Disturbance
total includes
disturbance.
Excludes any
abitat Name
Choose One
includes any
anticipated
restoration
.
any anticipated
restoration and/
restoration or
and/or temp
restoration or
temp impact
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 ❑

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that 1 own property adjacent to �7 L i D� Z�Iod -JC-yKt NS 's
(Name of Property Owner)
property located at � � IJVES 7 /e r o1�nL
C ( A Ad ress, Lot, Block. oad, etc.)
on AI2� /� u l in L� , N.C.
(Waterbody) (City own and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location
I have no objection 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)
'S� aPa- -x4,&- -1- it 12-0-/L
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.)
Y I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
teroperty owner In f rmation)
Eature
if
l ,,j
Print or Type Name nn
(Ad
jacent Property Owner Information)
}7Ti�1J�ll�
Srature *
Print o►'Tyype Na e

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to q L 1w- /us s
property located at i D WEI T k ( 4(Name of Property Owner)
r ) p Address, Lot, Block/ oad, etc.)
on �Airu:.L►��N G Lc)� in (✓� N.C.
}
(Waterbody) (City own and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc ti
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 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)
Signature f% J
A)
'Print or Type Name
zQ (.l%CI K/��P.
(Adjacent Property Owner Information)
Signature * // pp
_v •--, s VE i� N c .--,,-i
Print or Type Name
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