66308D - Mann

(LAMA'/'❑ DREDGE & FILL
3ENERAL PERMIT
SNew ❑Modification El -Complete Reissue ❑Partial Reissue
A B
Previous permit # ;r-
Date previous permit issued
sized by the State of North Carolina, Department of Environment and Natural Resources
Zoastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
❑ Rules attached.
it Name Tim s L—j Ste- T16 N 6 Project Location: County PF N t - (--
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t � (i A 0 StateN U ziP 77 ';YD
E 6-il_ S ` W' E-Mail
:ed Agent JW t"-DUSE Mi4lVe /o
O CW ^EW /iZFTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ' ❑ M ❑ URA ❑ N/A
❑ PWS:
yes f� PNA 4�no
f Project/ Activity
�k) length
atform(s)
Plat(orm(s)
iier(s) `.,
ngth
tuber
d/ Ripraplehgth
g distance offshore
ix distance offsli e
cannel \
Street Address/ State Road/ Lot #(s)
0 " i' % i, c j,
Subdivision
ZIP
Phone # (- River Basin CF
Adj. Wtr. Body l r Sv VA WW
Closest Maj. Wtr. Body ��� l.I i SU`J
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not sure
yes ENE ■■■■■■M■■Y■li W!9[i:
yes
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(Scale: I I 1
c,.� 7 t� f2-Ir:- C.-11 t- t�
ng permit may be required by: l ❑ See note on back regarding River Basin n
Local Planning Jurisdiction)

NC Division of Coastal.M9t- Habitat impact Computer Sheet
GZ�
Applicant: SA-
r7%l
Date:
Describe below the HABITA 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 FIN,
(Applied for. (Anticipated final (Applied for. (Ant
DISTURB TYPE Disturbance.total disturbance. Disturbance dish
Habitat Name Choose One includes any Excludes any total includes Excl
anticipated restoration any anticipated rests
restoration or and/or temp restoration or teml
ternimpacts)_impact amount) tem im acts amc
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Other [IDredge El Fill 0 Both ❑

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to l (n^ �i S� /�h01 n s
(Name of Property Owner)
property located at 6 ,si Sp ° 4 �ki
on Lr (Address, Lot, Block,,Road, etc.)
�� rPrs CAM (d�(n CG�c���� _,in C;+ , N.C.
(Waterbody) (City/Town ind/or County)
The applicant has described to me, as shown below, the development proposed at the above
Iocatign.A /
�� Ulf I have no objection to this proposal.
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, boat ramp, breakwater, boathouse, lift, or groir
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.)
Ido wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Inf rmation)
S. ignature
(Adjacent Property Owner Information)
Signature
Print or Type Name
Print or Type Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to I m b S Ck ILd6 r1 's
—„ — i ; (Name of Property Owner)
property located at
on
�(Adress, Lot, Block Road, etc
rr , in i N.C.
Npire (City/Town and/orl County)
The applicant has described to me, as shown below, the development proposed at the above
,,�pn
-- 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
understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groir
must be set back a minimum distance of 15' from my area of riparian access unless waived b�
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 Infor ation)
Si nnaat-ure
krv, I I t �a M a�n ✓�
Print or Tvna Name
(A00ce t Proa wner Information)
Si nature * wY ev
,'en n i fer & `Sand li o
Print or Tvoe Name

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