67152D - Marshall

CAMA / ❑ DREDGE & FILL �V {��3/ 1 ""-f V119
"ENERAL PERMIT Previous permit #
New ❑Modification ❑Complete Reissue ❑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
i i Rules attached.
:Name & AN 9- : W PrP;Eb�O�_
State( ZIP :'-
()2l0 E-Mail
�d Agent �i�✓/d !mac^ ,cis
❑ CW XEW [9�PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UIRA ❑ N/A
❑ PWS:
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision N
City V!'' F C--1YI4 ZIP Z-S+4
Phone # ( YRiver Basin
Adj. Wtr. Body To/' -SA t t-
✓es / no PNA �esno Closest Mai. Wtr. Body �cr-��t ie✓ SvL�ni(z
Project/ Activity 1�v15'f /� �( !J� -r_ ✓ G'��(T��' �oGs f �/
MMEMMMMMM M
MOROMMM W, M
MIM.I.M.1 M
11/�;rl_'JN��■ SIIi11YI oi
mmammmmml
igth
nber
!/ Riprap length_
distance offshore-
( distance offshore
annel
is yards
p
oat Lift >
r
not sure yes no
im: n/a yes no-)
yes no j
[[ached: yes no O
g permit may be required by: S*/0 ❑ See note on back'regarding
re River Basin r
g g
ocal Planning Jurisdiction)

' NC Division of Coastal .Mgt. Habitat IMP211ct' COMP titer 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.
FINAL Sq. Ft.
TOTAL Feet
it
(Applied for.
(Anticipated final
(Applied for.
Disturbance
(Ar
dis,
DISTURB TYPE
Disturbance.total
includes any
disturbance.
Excludes any
total includes.
Exc
Habitat flame
Choose One
anticipated
restoration
any anticipated
res
ten
restoration or
temp impactsimpactsl
and/or temp
im act amount
restoration or
temp impacts
am
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge El Fill Both ❑ Other El
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑. Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill 0 Both ❑ Other ❑

AGENT AUTHORIZATION FOR CANIA PERMIT APPLICATI0N
Name of Property Owner Requesting Permit: )9 /9 e.s 6AZ
Mailing Address: P
/%i
Phone Number: 2ze ,-,q-10 G/ / (F
Email Address:
I certify that I have authorized
% 50 l
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
w
necessary for the following proposed development: 5 2/445 i" // Al
Ili
vU'))V Sh,Pe" /OP.541.
at my property located at �f ��4 %t!!? *0 !�.), T
in Pe4,e aCounty.
I furthermore certify that l am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
%wwal
Signature
m gtn> A A M z42-5 h ►g- I I
Print or Type Name
Title

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
x Nanie of Pfoperty Owner)
property located at
Address, Lot, Block, R a Z
c.)
on Lf� in k N.C.
(Waterbody) (City/Tow and/or County)
The applicant has described to me, as shown below, the development proposed at the above locatior
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)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bacl
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wai
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) (Ad'acent P operty Owner Information)
-s-
Signa0ure Signature T 07-19
Print or Type Name Print or pe Name n

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to J!/�k 1�CX S. A I
t (Nam of Property O nw er)
property located at
2 l6 L; �t1E
(Address, Lot, Block, Road, etc.)
on _Tc in ' i'r 4 1,%y , N.C.
(Waterbody) (City/Tow and/or County)
The applicant has described to me, as shown below, the development proposed at the above locatix
,J7jl 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)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bacN
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wai
the setback, you must initial the appropriate blank below.)
I do wish to waive the 16' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Sw*ature
173�i74gnW %41
(Adjacent Property Owner Information)
Y°
Si ' ature Ll
.-J"(-'",4 -rP-Acy !�;r—1
Print or Type Name

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AAAIlle
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