66560D - Moore

CAMA /1 DREDGE & FILL
PE ERAL PERMIT 1 Previous permit # A B
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 I SA NCAC
J Rules attached.
Name y S n G. Ir Project Location: County �' �r. "-A ! l! w ✓
JL � .' ' Street Address/ State Road/ Lot #(s)
Attj t^,Q t Lt State ZIP �2G ZLC> i �, bi la H, li� k '-)lr-f't4`
( ) 1 + E-Mail t _ y� .
:d Agent , H W 10 V11A- ��.� yr 1
❑ CW ❑ EW ❑ PTA *S XPTS
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
ees (nod PNA yes / no)
Project/ Activity
k) length_
tform(s) _
'latform(s)
igth
fiber NY
�T
�Riprap length
distance offshore
c distance offshore 0 "
annel
is yards_
p
;e/ Boatlift
MOO Aiph
Length
not sure yeso
um: n/a yes no
qes no
attached: yes no
Subdivision Is
City j t'�JJJCLIX ZIPT
Phone # O 1 River Basin
Adj. Wtr. Body Jki AleVL` L (nat n
Closest Maj. Wtr. Body
r.
(Scale: j
ig permit may be required by:
-ocal Planning Jurisdiction}-.—, e t k ;
❑ See note on back regarding River Basin rt

IC Division of Coastal Mgt. Habitat Impact Computer Sheet
Permit #
pplicant: `
: 5
late.
escribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
)und in your Habitat code sheet.
abitat 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
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
50
Dredge ❑ Filw Both ❑ Other ❑
51)
i7
Dredge ❑ Fill Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other -X
l u V o
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 ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
l
Name of Property Owner Requesting Permit: �L 3 ic—A it E ! % �'16 a1L
Mailing Address:
Phone Number:
Email Address:
q1 6 S ZC C(40 '�'
A I'A c3
I certify that I have authorized 6 ka
Ar►
to act on my behalf, for the purpose of applying for and obtaining all LAMA permits
necessary for the following proposed development:
at my property located at
in i �. NAt,�a4 r County.
1 furthermore certify that 1 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:
Signature
M k,4-V—' ol �J('n 0 tLE Print or Type Name
Title

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
1Name of Property Owner)
property located at _ �.3 a-@� S 1� , N� � >3S �;
(address, Lot, Block, Road, etc.)
on in ?�(7 w � s�r+.)tti � �°r-'4, N.C.
(Waterbody) (City/Town and/or County) a
The applicant has described to me, as shown below, the development proposed at the above locati
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 bac
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to w<
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)
,signature
Print or Type Name-
( =sue � �'r Z .� J �� S
Mailing Address
r Information)
%� f Y7

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I
I hereby certify that I own property adjacent to t l C 1 ow�vl r' o s
property located at
(Name of Property Owner)
%��lS Saint � o.�� s f
(Address, Lot, Block, Road, etc.)
on AC In -, in Carolans k_4t_L- , N.C.
(Waterbody) (City/Town and/or County)
tt T scant has described to me, as shown below, the development proposed at the above locat
Y
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 bw
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to w
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 Own Information) (Ad'acent Property Owner I rmation)
950
I �
Signature Signature
. c Mbo J Hiram Tucker
Print or Type Name \ Print or Type Name
SGi"A PO Box 110
Mailing Address Mailing Address

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