66323D - Lee

ICAMA / El DREDGE & FILL
3ENERAL PERMIT -)
New ❑Modification El Complete Reissue El Partial Reissue
wized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
A B
Previous permit #
Date previous permit issued
1 ❑ Rules attached.
it Name Or, Project Location: County
Street Address/ State Road/ Lot #(s)
I'OF " V ✓r State U ZIP
' > E
�-? `� E-Mail Subdivision 1f �
ted Agent -E- Olk C . City ; j; �;lz.� ' � �? Ci ZIP f�t
❑ Cw ❑ EW �(BTA ❑ ES ❑ PTS Phone # ( ) River Basin r"�l
❑ OEA ❑ HHF O IH ❑ UBA ❑ N/A Adj. Wtr. Body
❑ PWS:
yes / no PNA yes
Closest Maj. Wtr. Body ��' - �
f Project/ Activity J
)ck) length -
latform(s) — .__
: Platform(s)
mibeamber
id/ Riprap length
g distance offshore_
ax distance offshore
hannel
mp N
ise/ Boatlift
fulldozing
ie Length r
not sure yes
rium: n/a yes
Attached: yes �rro ��f /•
ing permit may be required by: See note on back regarding River Basin r
Local Planning jurisdiction)

SIC Division Of (;Oasxal 01911% "141"t 11"T'
Applicant: (� ✓ S �' `�� .
vV 1
Date: -- % b
- Describe below theAB1TAT 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
Fli
(Applied for.
(Anticipated final
(Applied for.
(At
dis
DISTURB TYPE
Disturbance.total
. includes any
disturbance.
Excludes any
Disturbance
total includes.
Ex
Habitat Name
Choose One
anticipated
restoration
any anticipated
re;
restoration or
tern im
and/or temp
impact amount
restoration or
temp im acts
ter
art
/acts
Q ((J
Dredge ❑ Fill 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 ❑

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date �� /�L'Z
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent) v C,)iu 0 to act on my
behalf, for the purpose of applying for and obtaining all CANIA Permits necessary to
install or construct (activity)
at (my property located at)
This certification is valid thru (date) Z'3 0

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to .hiu, 15` wd� , lie, 's
(Nan a of Property Owner)
property located at /ems 60r`f K 1406
(Lot, Block, Road, etc.)
on !r a""14i , in l EP.�O,�z d sa,4,- , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: ilC 30 oZ k j Mailing Address: % D2 C�
He has described to me, as shown below, the development he is proposing at that location, and, I
hove no objections to his proposal. I understand that a pier/mooring pilings / boatlift I bosthoUse
nk, be set back a minimum distance of fifteen feet (15') from my area of riparian access unless
w4ived by me. (If you wish to waive the setback, you must initial the appropriate blank
bole".)
)IL I do not wish to waive
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
-------------------------------------------------------------------------------------------------------------------
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit) p
o?; 0 AA1101
Mailing Address Signature

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to �� / Lea, is
(Nan4e of Property Owner)
property located at Its—
yor y k A
(Lot, Block, Road, etc.)
on ca.zo_i , in %-Flpy� 464 4- , N.1
(Waterbody) tTown and/or County)
Applicant's phone #: �Jle30 a6i Mailing Address: `l 2 17k-l'glx CIL
tk ! 4lE a , xL a&43
He has described to me, as shown below, the development he is proposing at that location, and
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathou:
must be set back a minimum distance of fifteen feet (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 not wish to waive
y K" I do wish to waive that setback requirement. }�� I co c oer JIVM
-----------------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
-----------------------------------------------------------------------------------------------------------------
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
o2 ae m? A"C611 el )
Mailing Address Sianati

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