67162D - McCall

CAMA / ❑ DREDGE & FILL
MNERAL PERMIT
Previous permit#
flew ❑Modification ❑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 V�T1 • �UV
� ( l
�J ❑Rules
Name (A c � 1 � V'
Yched.
Project Location: CountyT Sonl
LQ, (� �}
Street Address/State Road/ Lot #(s)
LA VYQ YA L
. State ZIP�t�
() j E-Mai
Subdivision
�d Agent �, e
<J h
ZIPg���q
❑ CW �ATA ❑ ES ❑ PTS
/d1-(,City t+
Phone # )1104-30 er Basin
❑ OEA El El11H ElUBA ElN/A
Adj. Wtr. Body �� �� nat
ElPWS:
, , R
yes no/ PNA yes /ro�
Closest Maj. Wtr. Body �w
�
rroject/ Activity
A) length
Rform(s)
Platform(s)
er(s)
igth
nber
I/ Riprap length
distance offsh) re
x distance ofj�hore_
annel /
Length
kttached:
W
ig permit may be required by: iJtAM 0 UQA n s K $-Ml h ❑ See note on back regarding RiverBasinn
Local Planning jurisdiction) �' ,� - I j - I r >; �, it

Aid Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: / ` "(c .j � Permit #: c 7
Date: o b /(-7
(o-
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet FINAL Feet
(Applied for. (Anticipated final
Disturbance disturbance.
total includes Excludes any
any anticipated restoration and/or
restoration or temp impact
temp impacts amount
DVj
Dredge ❑ Fill ❑ Both ElOther
�q /ou
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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both El Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

r
Name of Property Owner Requesting Permit: %. c
Mailing Address:
Phone Number:
Email Address:
1 certify that t have authorizedi
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessaryfor the fbl development
owing Proposed oilmen
C� 7 i
at my property located at
in Dr -S 4=,,- County.
C
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and fhsir agents to enter
on the aforemenilimmW lands in connection with evaluating kdbrmatron related to this
permit application.
Property Owner kformation:
ire
Pfint or Type Name
Y" 1 V lei v

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
me of Property Owner: eA
(dress of Property:
(Lot or Street #, Street or Road, City & County)
lent's Name J Mailinq Address:
lent's phone 0 --<46 C'j�1 _ yC' ;,�.4(,- %
iereby certify that I own property adjacent to the above referenced property. The individua
)plying for this permit has described to me as shown on the attached drawing -the developmen
ay are proposing. A description or drawing, with dimensions, must be provided with this letter.
141
I have no objections to this proposal. I have objections to this proposal.
,ou have objections to what is being proposed, you must notify the Division of Coastal ManagemeI
.M) In writing within 10 days of receipt of this notice. Contact information for DCM offices
vilable at http.lAvww.nccoastalmanatrement.net/web/cm/staff-listlno or by calling 1-888-4RCOAS'
response 1s considered the same as no objection N you have been notified by Certified Mali.
WAIVER SECTION
nderstand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift must
set back a minimum distance of 15' from m area of riparian access unless waived by me.
u wish to waive the setback, yo s in stl fhe appropriate blank below.)
4 I do wish to waivethe 15' setback requirement. r-fo t2l X-5- 2t'
I do not wish to waive the 15' setback requirement.
Property Owner Information)
signature
A) c- KL(f'AL/—
lint or Type Name
(Riparian Property ner info on)
9�
ignat re
IVY
Print or ype Name

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF GOASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: 4L � e- (+A Lam.
Address of Property: ��'� <2 3 /Uc�-
(Lot or Street #, Street or Road, City & County)
Agent's Name #: I� i ��s�� Mailing Address:�p
Agent's phone #: 2U -1 —6(-6 ryCa R /UC
I hereby certify that I own prop" adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions must �baii ovided with _thiK> letter.
I have no objections to this proposal. I have objections to this proposal.
�.7
If you have objections to what is being proposed, you must notify the Division of Coastal Management
(OCM) in writing within 10 days of receipt of this notice. Contact Information for DCM offices is
available athtt://www.nccoastalmana ement.net/web/cm/sta -listin orbycalling 1-888-4RCOAST.
No res onse is considered the same as no objection if you have been notified bX Certifled Mall.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift must
be set back a minimum distance of 15' from m area of riparian access unless waived bit me. (If
you wish t waive the setback, yo -' us init al he appropriate blank below.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
Print or
rrJType Name
Mailing Address
(Ripa ian P pe Owner Information)
S ature
11
, . C."
Print or Type Name
� � f S
. MAing Address

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