67234D - McKenzie

]CAMA / ❑ DREDGE & FILL 2
.EN ERAL PERMIT ILI, I v I l Previous permit # A B
ZNew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources '] /�
.oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC 'J 1 I I l V/�o
❑ Rules attached.
t Name �J 0 h S L�� Project Location: County�1n,'
QC? Ic 4-b t� `�-� Street Address/ State Road/ Lot #(s)
1
C, ViN wr b b1 StateN_ ZIP
61 _ j I -i_Mail '__.__. — Subdivision
ed Agent 6, it V't ik' l Vk 5 ? oc► ZIP age
ElCW P(EW j(PTA ❑ ES ❑ PTS Phone # (1 ) W ]' ti 0 1 ver Basin '�'�rVl�^
I] OEA ❑ HHF �❑ IH ❑ UBA ❑ N/A {�
❑ PWS: ✓✓✓llV//���
yes / no PNA yes /i
' Project/ Activity ✓, :'�J tiV
ck) length_
►tform(s)
Platform(s)
ngth
nber
i/ Riprap le gth
distances ffshore
x distance offshore
r
cannel
)i ds
ip
se/tl
illdozi`ng
a Length C
Ad{. Wtr. Body : ;1 V nat
Closest Maj. Wtr. Body
✓ 1 1 ' 1 �'._71 ( of Y `
New "UNIN& Lim, a P.
MEMONEM M
I US HWJ-Q
XL V�'
(Scale:
_ocal Planning jurisdiction)
li 1 f
❑ See note on back regarding River Basin m

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: al�w�u`� Permit #;
Date: t V l V/ 6i
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
TOEi
t
FINAL Feet
(Apptied.for.
(Anticipated
(A
(Antioipatedfinal
Habitat Name
DISTURB
TYPE
Disturbance total
disturbance.
Di
disturbance.
Choose One
includes any
Excludes any
tot
Excludes any
anticipated
restoration
any d
restoration and/or
restoration or
andfor temp .
resr
temp impacttemp
impacts)
im act amount
tem.)
amount)
C/ W
Dredge ❑
Fill ❑
Both ❑
Other Ix1
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge El
Fill El
Both ❑
.Other El
Dredger
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑

'ayment Proccessing Confirmation
)ate Received 11/18/2016
:heck From (Name) Backwater Marine Construction Inc
Vame of Permit Holder Joseph & Gypsy McKenzie
✓endor BB&T
:heck Number 2536
:heck amount $200.00
Multiple Permits No
Major/Minor
'ermit Number/Comments GP 67234D
teceipt or Refund/Reallocated SF/2573D

2 e-,P -LZ-
Aga
�
North Carolina Department of Environment and Natural Resources
0a'C John E. SI
;;cver�or
sea
N C Divis,or of Coastal Management
AGENT AUTHORIZATION FORM
Date ld-1 ••ff--e
Name of Property Owner Applying fcr Perm, Name of Authorized Agent for !his orolect
o�ol� Gt ps� lV ck 3e,411z I —A— __tine __ A(t \fV1115 - --
Owner's Mailing Address
Agent's MaUirtg Address:
Emad - -��-ii— q a—`--Ca--e—�-- Emsd An[ S %d
Pn�r,P �T�1- 6 %O ` ! Z-J� Phone
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 PermitsnecessarM? install or construct the following (activity)
For my property located at d
This certification is valid I year from rca!el

CERTIFIED VI -AIL IL — RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY. O'WIVER STATEMENT
Name of Property Owner:
Address of Property: 1990 — ',--�PQI Kre U MI
(Lot or Street #, Street or Road, City & County)
Applicant's phone #:�3(r,—q I � - (q9 5 Mailing Address: I Is � roc��tar.� C)u
C � cjnrnO� 1�►Q7lJ a
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this p,
has described to me as shown on the attached drawing the development they are proposing. A description of dray
wit i di�*onsusrovided w}th this letter.`7bjections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (D(
in writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive
Wilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No response
considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be setback a minimum distan
15' from my area of riparian access unless waived by me. (If you wish to waive the setback, you must initial th
ap o ate blank below.)
I do wish to waive the 15' set back requirement.
I do not wish to waive the IS' set back requirement.
(Property Owner Information) / Q
i ture
Lang 4c Im 5
Print or Type Name
/ qo'-7 k l b�j
Mailing Address
SU�d/I J U I -
- - s Q�\csQ
Print or Type Name V
L b
Mailing Address
City / State / Zp
Telenhone Number q140' 7`J— ` ff9u
City / Stafe / Zip it
Telephone Number - ��

CERTIFIED N�LAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner:
EN
Address of Property: 1 C I-11 YL IvL If �4 c;/-
(Lot or Street #, Street or Road, CG & County)
Applicant's phone #: - �� g' IGc1 S- Mailing Address: I I P-oCY�On CuV+-
�'le mrnc��5 , NC a7a
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this pe
has described to me as shown on the attached drawing the development they are proposing. A description of draw
with dimensions, must be provided with this letter.
a I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DC
in writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive
Wilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No response i
considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or Iift must be set back a minimum distant
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.)
ZVI do wish to waive the IS' set back requirement.
I do not wish to waive the 15' set back requirement.
(Property Owner I formation)
A q e tiA
Sign re
Lane- Od mS
Print or Type Name
190'7 Kt rbu rd . S�
Mailing Address
�LtopILi W-
City / State / Zip
Telephone Number
(Riparian Property Owner Information)
Signature
Print or Type Name
ai ing Address
! ate / p UZ
Telephone Numbe4//- ,� "/

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