67923D - McKinney

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NC DivIsaon of Coastal Mgt. Habitat impact Computer Sheet
Applicant: ' V e"
l6Date: 1t
Permit #: G 7 q Z,l - �,
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.
FINAL Sq. Ft.
TOTAL Feet .
FINAL Feet
(Appiied..for.
(Anticipated #trial
(Applied foc
(Anticipated final
Habitat Name
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
resto[ation
any anticipated
restoration and/or
restoration or
andfor temp
restoration or
temp impad
tem impacts
impact amount
tempimpacts.)
amount)
V " _
Dredge ❑
Fill Both ❑ Other ❑
l Q C)
CO
Dredge ❑
Fi Both ❑ Other ❑
do
Dredge ❑
Fill ❑ Both ❑ Other ❑
Dredge,❑
Fill ❑ Both ❑ Other ❑

payment Proccessing Confirmation
Date Received 11/9/2016
:heck From (Name) Backwater Marine Construction Inc
Name of Permit Holder Kent McKinney
Vendor BB&T
Check Number 2598
Check amount $600.00
Multiple Permits Yes
Major/Minor
Permit Number/Comments GP 67923D ($400)
Receipt or Refund/Reallocated SF/2838D

Pat WCrory
& LV 3- A
-if EnV ,,riif1"pent arx+ Natur? Resources
N.0 Divisi: , f ;as;a #.Management
John E. SkvF
Secret,
AGENT AUTHORIZATION FORM
Date —Y 4z1(fl - —
Name of Property Owner Applying for Permit. Name of Authorized Agent for this project:
Owner's Mailing Address.
Email.—P-j,_'�!����.�� . L
Phone L : % `7✓ — Z 4 .2-9
Agent's Mailing Address.
Email. C�l�t r 5 ��� C� Yiu•� C[i
Phone did
I certify that I have authorized the agent listed above to act •.y t>eha!` i'. the purpose of applying
for. and obtaining all CAMA Permits necessary to in/stall or -,on/struct the following (activity).
/� r � fc t e . •F% �} - 11'� /1 Cam_ i ' r3'
For my property located at i� �y���•-'r %.c ,r _ L'� `. C__ r
This certification is valid 1 year from (date) �' "

ADJACENT RIPARIAN PROPERTY OWNER STAT
EMENT
I hereby certify that I own property adjacent to �wu &&- e ` z 's
�� _ 1 / (Name of Property O er)
property located at < ✓I l ( s
(Address, Lot, Block, Road, etc.)
on C'aN�.l !3N �.L L'�, in Q Z 1� : �f U �.�o,� N.C.
(Waterbody) (City/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)
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44-
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WAIVERSEC'rION O"T'B'
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.)
KI do wish to waive the 15' setback requirement.
I ao not wish to waive the '15 setback requirement.
(Property Owner Information) _ (Adjacent Property Owner Information)
Signature / Ysignature
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Print or Type Name n Print or Type Name
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C
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to f'� / ' 4 l�� h J 2 's
(Name of Property Owner)
property located at
(Address, Lot, Block, Road, etc.)
on in _._ �`- L ('J ""� N.C.
(Waterbody) (City/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)
C>V-�.- QN IQ
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) Adjac/epgt Pr'ope er Information)
Signature _ .Sir ul re �� � V a 0
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