66624D - Pruitt

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�CAMA / ❑DREDGE &FILL .�
GENERAL PERMIT Previous permit # A B
New ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued `
)rized by the State of North Carolina, Department of Environment and Natural Resources L
Coastal Resource Commission in an area of MjwironmeMatco ant to 15A NCAC 14 � !
7T/ ElRules attached.
it Name Project Location: County
s KA
>0 d rl e41- State A L ZIP 07 5-2.1
0) (_5`'>E-Mail
zed Agent rt'
i ❑ CW EW �CPTA )ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ K/A
❑ PWS:
yes PNA yes � /
if Project/ Activity jrtil7 �(
ock) length
'latform(s)
g Platform(s) /
pier(s) (�
ad/ q* length J
"vg distance offshore
iax distance offshore
channel
ubic yards
Street Address/ State Road/ Lot # s)
�'-
Subdivision
City C ZIP
Phone # ( I River Basin
Adj. Wtr. Body
Closest Maj. Wtr. Body
!w c 16
❑ See note on back regarding River Basin

NC D'viS' of Goa�tal .Mgt. Habitat Impact computer sheet
licant: �01 / v
App (i(/Z
Date: ���� / v
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 W
(Applied for. (Anticipated final (Applied for. (An
DISTURB TYPE Disturbance.total disturbance. Disturbance disl
includes any Excludes any total includes . Ex(
Habitat Name Choose One anticipated restoration any anticipated res
restoration or and/or temp restoration or tern
tempimpacts) impact amount tempim acts am
oV v Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill Both ❑ Other ❑ v l V
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑. Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at bro�
on Ca N6LI
(Waterbody)
(Name of Property
.% _ , _ r -
(Address, Lot, Block, Road, etc.)
in SG1 +Q �' i N. C
(City/Town an /or County)
The a plica has described to me, as shown below, the development proposed at the abov,
to
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, boat ramp, breakwater, boathouse, lift, or gro
must be set back a minimum distance of 15' from my area of riparian access unless waived t
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)
VlAf
Si atu Q ,/i "Ok!
(AdjWr>ioropei4y gwner Information)
Print Ar Tvna Names Print or Tvne

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to _ S�-G✓-G� C , ( .',, 4t — s
property located at o� f� (Name of Property Owner)
J`U 0-1- 4-/U
on C c{ Na-1 (Address, Lot, Block, Road, etc.)
in Sit of P N.C.
(Waterbody) (City/Town an/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
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)
S & C 0. ?-'Tq C—k /►a ErN +
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
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.
(vroperty Owner Information)
Zg4turpJV.1
NG �r`ain
Print or Tvoe Name
(Adjacent Property Owner Information)
Signature
<A-ev{,rt
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