66374D - Koonce

�CAMA / ❑ DREDGE & FILL V 10,1 1�6
A B
oENERAL PERMIT Previous permit#
New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
-iced by the State of North Carolina, Department of Environment and Natural Resources L
;oastal Resources Commission n an area of environmental concern pursuant to 15A NCAC
K-U&E
R )es attached.
t Name i � �-� 4 Project Location: County
State-ZIP
)� (a-)E-Mail
ed Agent
❑ CW NfW TA ❑ ES ❑ PTS
ElOEA ❑ (
HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes no ) PNA yes / no
' Project/ Activity
ck) length
atform(s) -
Platform(s) /
ier(s)
ngth
tuber'=
' � I
d%Riprap length
distance offshore
uc distance offshore
cannel —
bic yards
np
ise/ Boatlift
ulldozing
I
i
f
' I
I
ie Length
Ium: n/a yes no
yes no 1
Attached: r yes no
ing permit may be required by:
Local Planning lurisdictionl
Street Address/ State Road/ Lot #(s)
Subdivision
City j ,4', r �� ZIP Z-OD
Phone # River Basin
Adj. Wtr. Body, n} —Alrr p ^.�%% Ee ,kr�ac
Closest Maj. Wtr. Body
r �
❑ See note on back regarding River Basin

NC Division of Coastal .Mgt. Habitat impact Computer Sheet
Applicant:
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. FIRIAL Sq. Ft. TOTAL Feet M
(Applied for. (Anticipated final (Applied for. (An
DISTURB TYPE Disturbance.total disturbance. Disturbance disl
Habitat (dame Choose One includes any Excludes any total includes Exc
anticipated restoration any anticipated res
restoration or and/or temp restoration or tern
,..,.., f --nfl tPMn imnacts) am
Dredge ElFill
ElBoth
❑
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 ❑ I L

IACENT_RIPARIAN
I hereby certify that I own property/adjacent to
property located at
on / ,/i
(Waterbody)
i ue--(2— 's
Name/bf Property Owner)
ss, Lot, 949ck, Road tc.)
in tie ' r N.C.
(C(ty/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill in description below or attach a site drawing)
P O.A-A 1 C J0 C- k- L\
i
ri�(Accf,X,WvUele Pam", w,—�
` J
ex
J ST c S f v S o v�C7 �o tr"�- 1 v1 s
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/�o wa�he 15' setback requirement.
fra'!% I do not wish to waive the 15' setback requirement.
(Prop ft Owner Information)
�ignurure
Print or Ty Name
(Adjacent Property Owner.lrlformation)
sigma' J el/'
Print or

NT RIPARIAN
I hereby certify that I own property adjacent to d 44,,
me of Property Owner)
property located at / — �r F�
�= ( ress, Lot, I ck, Roa , etc.)
on , �` in - �- N.C.
(Waterbody) ( ity/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
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)
JO WC) L') CP
re (A C� �-t Y C woo,-'p r A,'�-,
;,l v 14 f-,A Lk-11 'v' fJ LA
r f 4-A c
+''" � ; `, .�• S I v o V^c �o ram- + v� s
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.
(PrY
Owner Information)
If � a� 6-
.signature
Print or T' Name
N�� 1-s
(Adjacent Property Owner Information)
o
Signatur * /
Print o� ypP Name,

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