66314D - Lumsford

ICAMA 11:1 DREDGE & FILL K L f 'permit
3ENERAL PERMIT vj JJ�Jl�
PreviousP ermit#
New ❑Modification El Complete Reissue El Partial Reissue Date previous permit issued "
Ized by the State of North Carolina, Department of Environment and Natural Resources
.oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
❑ Rules attached.
t Name 4 L' t/'' `?� 4 �%', Project Location: County �.
1?, , Q 0 Street Address/ State Road/ Lot #(s)
Stated ZIP`"'?
E-Mail /_ _ Subdivision
ed Agent /� PEEL G-/"y" �, City %�'r ZIP
—r--fi'
❑ CW )VWW ,k�*TA ❑ ES ❑ PTS Phone # () River Basin
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ WA '
El Pws: Adj. Wtr. Body-' ,rl� d i ai/f � n
yes Frio:; PNA yes ! no j
Closest Maj. Wtr. Body'
Project/ Activity
-k) length i _
igth
nber
I/ Riprap length
distance offshore
K distance offshore
annel
is yards
ip
d 'ng
Length
not sure yes
um: n/a yes
yes 'jE'9p
ttached: yes no
(Seale: J %l
r
g permit may be required b" `1
.ocal Planning jurisdiction)
❑ See note on back regarding River Basin

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant:
Date:
Describe be5low 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
FI
(Applied for.
(Anticipated final
(Applied for.
(A
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
di:
Habitat Name
Choose One
includes any
Excludes any
total includes
Ex
anticipated
restoration
any anticipated
re:
restoration or
and/or temp
restoration or
ter
temp impacts)
impact amount
tem im acts
art
Dredge ❑ Fill ❑ Both ❑ Ot
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ ' Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

NC®ENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis
Governor Director
John E. Skva
Secrete
AGENT AUTHORIZATION FORM
Date: 3 l K 16
Name of Property Owner pplying for Permit: Name of Authorizes! Agent for this project:
��. LoI
Owner's Mailing Address:
6 12 n/1aI'd 7-�
E —761Z
Phone Number (111)
Agent's Mailing Address:
Phone Number
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):
For my property located at 60(-I5 ScN ePA- SwC�°F'�-� IU- Zg(Icf5
This certification is valid thru (date)
Property Owner Signature Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �
� (Name of Property Owner)
property located at (�� �{ S � 5��� -
(Address, Lot, Block, Roadt�c.)
on Ccnn�Q in , N.C.
(Waterbody) (City/Town an or County)
The applicant has described to me, as shown below, the development proposed at the above
loc a --
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
c Ywf
AV-J WJ (c wkv_
6 CM -7
E
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or grc
must be set back a minimum distance of 15' from my area of riparian access unless waived I
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)
Si nature / n
(Adjacent Property Owner intormanonl
l - J �
ignature

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Ke.) -�� - - N43�� � it- t-"Asl; s
(Name of Property Owner)
property located at (4 4 S [0
(Address, Lot, Block, Road, etc.)
on ,cM CS in C,±�"" , N.C.
(Waterbody) (City/Town an or County)
The applicant has described to me, as shown below, the development proposed at the above
ZP
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,
Pe.')
Nr) a" o K 5 a - "Y' WJ (c
6bM� 6
r Cze�' Ov-+ �
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groii
must be set back a minimum distance of 15' from my area of riparian access unless waived b
wish to waive the setback, you must initial the appropriate blank below.)
k7'1� I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
S1r nature /
lP�', ✓� (�. L-�(.tN�ShY ter!
(Ad'acent Prol erty 70wner I formation)
15ignatu.r
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