67280D - Nantz

(CAMA / ❑ DREDGE & FILL (�(/ / A B
NERAL PERMIT (Y Previous permit#
ew ❑Modification ❑Complete Reissue El 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 4 1/
❑JWles atrac ed.
i
t Name - �'f k Project Location: Countyyny`
Street Address/ State Road/ Lot #(s)
AVV✓'�)Y\ Mate , ZIP
"+ �I Subdivision
edAgent �'Vwy nk`_`, - ... City �^ i �'�6, ZIP
❑ CW 04W 'XPTA ❑ ES o PTS Phone # ( ) River -Basin
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A r \
❑ PWS:
PNA yes no
Project/ Activity
:k) length Is, YW
itform(s) l-2 ''' a'- f
�
Platform4s) ��
er(s)
igth
nber
I/ Riprap length
distance offshore
x distance offshore
lL
agnel �-
,ic yards
ip
;e/ Boatlg',
illdozing
Length
not sure yes no
um: n/a yes
Yes
no
attached: es no
ig permit may a "required
vocal Planning jurisdiction)
11 t x"a `rri
Closest Maj. Wt. :.. .�
(Scale: 1%
En
jid k JkL- ❑ See note on back regarding River Basin r

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant; -
Permit #:
as
Date:
I�
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
. FINAL Feet
(Applied..foi.
(Anticipated final
(Applied for..
(Anticipated final
Habitat Name
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
Choose One
includes any
Exeludesany
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/oi
restoration or
and/ortemp .
restoration or
temp impact
?1
r
temp impacts)
impact amount)
temp impacts)
amount)
❑ Both/IQ (Rtfi�tr ❑ K I n / _
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge [I
Fill ❑
Both []
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other
Dredge ❑ Fill ❑ Both ❑ Other El
Dredge ❑. Fi(I ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑. Both ❑ Other ❑
Dredge [] Fill ❑ Both ❑ Other ❑
Dredge.❑
Fill ❑
Both ❑
Other ❑
Dredge [IFill
❑
Both
Other ❑
Dredge 0 Fill ❑ Both .❑ Other ❑

� �ENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
: rory Braxton C. Davis John E. Skvarla, III
nor Director Secretary
AGENT AUTHORIZATION FORM
Date: l/ ,U -112CY6
if Pr-opperty Owner A lyin for Permit: Name of Authorized Agent for this project:
> Mailing Address:
> y
4umber - 6e
Agelnt�Mailing Address:
`� ,3. boy S03
0 Rk -1:4 C1'a n b U f aS
Phone Number (9/0) a 00 - /-7 9.3
that I have authorized the agent listed above to act on my behalf, for the purpose of applying
obtaining all CAMA Permits necessary to install or construct the following (activity)
property located at
tification is valid thru (date)
/ 1 Ma/
Property Owner Signature Date
l

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAIVER FORM
Name of Property Owner:
Address of Property:
Agent's Name #:
Agent's phone #:
or Road, City & County)
Mailing Address:
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions must be provided with this letter.
V 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
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at http:/lwww.nccoastalmanagement netlweb/cm/staff listing or by calling 1-888-4RCOAST.
No response is considered the same as no objection if you have been notified by Certified Mail
WAIVER SECTION
understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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.)
do wish to waive the 15' setback requirement
I do not wish to waive the 15' setback requirement.
'Property Owner Information) VIC
>ignature
'nnt or Type Name
failing Address
k (Riparian Propert Owner Information)
Signature
Print or ype Name
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11

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owi
Address of Property:
Agent's Name #: St 1 �—
Agent's phone #:
or Street #, Street or Road, City & County)
Mailing Address: l.xk,, Lc
VtL d 17 d-1 3�
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions, must be provided with this letter.
V 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
(DCM) in writing within 90 days of receipt of this notice. Contact information for DCM offices is
available at http://www.nccoastalmanagement.netlweb/cm/staff-listing or by calling 9-888-4RCOAST.
No response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information
j �11ti�
Signature
bvrm , --Re!:po lAs
Print or Type Name
(Riparian Property Owner Information)
Signature
Print or Type Name
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