66321D - Malpass

I CAMA / ❑ DREDGE & FILL 14 b, iV1 U � � A B
l
�EERAL PERMIT Previous permit#
kNew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources
.oastal Resour es Commission in an area of environmental concern pursuant to 15A NCAC li i F
--� ❑ Rules Auched.
t Name U+�� �S Project Location: Countyl ,(�(
f14
�t.� /1 �- �( UAtreet Address/ State Road/ Lot #(s)
Gt ✓ State /`z - ZIP t. et� L-7 Y f �' y LS
��� Z f �� E-Mail —`�� Subdivision
ed Agent !�7 l l d ��� Z.t iL(.Q City '� Lt '� ZIP
❑ CWfW EFTA ❑ ES ❑ PTS
❑ OEA / ❑ HHF / ❑l 1H ❑ URA ❑ WA
❑ PWS:
yes nog PNA yes /
' Project/ Activity
ck)length
itform(s)
Platform(s)
ier(s)
ngth
nber %
i/ Riprap length
distance offshore
x distance offshore
cannel,'
k yards
ip
s% Boadi Z
notsure yes
um: n/a yes
yes
attached:
ig permit may be required by:
_ocal Planning jurisdiction)
Phone # I ( ..... River Basin
Adj. Wtr. Body
Closest Maj. Wtr. Body
Ge.
/X
❑ See note on back regarding River Basin rt

NC Division of Ctaaatal .Mgt. Habitat impact* Computer Sheet
)plicant:
a� ASS
Ite: " (� ((,
:scribe below the HABITAT disturbances for the application.
values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL -Sq. Ft. FINAL Sq. Ft. TOTAL Feet F
NAL Feet
(Applied for. (Anticipated final (Applied for. nticipated fins
DISTURB TYPE Disturbance total disturbance. Disturbance sturbance.
abitat Name Choose One includes any Excludes any total includes, xcludes any
anticipated restoration any anticipated restoration and/
restoration or restoration or temp impact
and/or temp
,,�,1 amount/
h/ �Y Dredge ❑ Fill ❑ Both ❑ Ot
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge[] Fill ❑ Both ❑ Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge. ❑.
Fill ❑
Both ❑
Other ❑
Dredge ❑ Fill ❑ Both 171 Other 171

C�r
AR"A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Govemor James H. Gregson, Director Dee Freeman, Secretary
Date
Name f Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent) �> �6 e Al a '4_ to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at) / �/' �� el'S' /Ov"C / c O
This certification is valid thru (date)
&
Property Owner Signature Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to %4�q: & is
(Name of Property Owner)
property located at
Block, Road, etc.)
on I OASai ( 5D ✓y , in P17A1ji�CV , N.C.
(Waterbody) 11 (Town and/or County)
Applicant's phone #: q(o3(v7 Z16-1 Mailing Address: SZ ef
t10t ,esHw,4 --ve:- LBYy_
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
,�W — I do wish to waive that setback requirement.
-------------------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
REp(aCe F-)c(r n bei•ns r e�x,i
Aot,�- f-
-------------------------------------------------------------------------------------------------------------------
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
29gY/7 �e()tkZ4 It P V r����
Mailing Address V Signature

ie 0
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to J Ad 's
(Name of Proper Owner)
property located at o2 �� 6r(rdk - A "- 1(4;,Ij �r �0�� M0"``'
(Lo , Block, Road, etc.)
on t �'%��i�i� l �J �"'�' �dC , in �� � �c I%— -,N.C.
(Waterbody) Town and/or County)
Applicant's phone #:
9�r 3C-7 d 1,5-9 Mailing Address: (Fo? nl
/-4dhy5K-.sP ivc- zgy� j
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive /V
I ltq
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be ftlled in by individual proposing development)
I
(Information for Property Owner Applying
for Permit)
q($ ti L(,4 Pn e
Mailing Address
(Riparian Property Owner Information)
Signature