66683D - Pigg

,IA FA aEDGE &FILL
A B
PERMITIEL
Previous permit #
New ❑Modification ❑Complete Reissue []Partial Reissue Date previous permit issued
zed by the State of North Carolina, Department of Environment and Natural Resources lJ // I 1 r
Dastal Resources Commission in an area of environmental concern pursuant to I SA NCAC r 1 "1 ! 1 o i
❑ Rules attach
Name G N ` '' Project Location: County (2 �� j '
J�- Street Address/ State Road/ of #(s)
3(1� State ZIP C1 Q(l't 5t'
E-Mail Subdivision tJ!!
d Agent YAu hifY,,*v City"t-7 -yam
❑ CW EW A ❑ ES ❑ PTS one # ( —�) Q — 1 9 7 ver Basin
❑ OEA ❑ HHF ❑ 11H ❑ UBA ❑ N/A Adj. Wtr. Body l l( A (nat
❑ PWS: , � A A
PNA yes / Eioj Closest Maj. Wtr. Body V�/V
es / ©° �+
Project/ Activity tl CIO
Jj wi
k) length_
.form(s) (
'latform(s)
gth
fiber
IRiPraP
distance
innel
P
e/ atlift
119
Length :�
not sure yes
um: n a yes
attached: �e no
ig permit maybe required by: 1y �" O LC �� IKk
_ocal Planning Jurisdiction) _/7
(Scale:
❑ See note on back regarding River Basin rL

NC'Dirr sloe of Coastal. Mgt. Habitat Impact Computer Sheet
Applicant: �� Permit #:
Date:
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet
Habitat Name
TOTAL Sq. Ft.
(Applied -for.
DISTURB TYPE Disturbance total
Choose One includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft. TOTAL Feet .
(Anticipated final (Applied for..
disturbance. Disturbance
Excludes any total includes
restoration any anticipated
and/or temp , restoration or
amount) temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/oi
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Other 5�
�im-lpact
1
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge.❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other El
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 El Other ❑
Dredge ❑ Fill 0 Both ❑ Other ❑

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
Mailing Address:
4-1 -2& �/- yea- - q0s?
I certify that I have authorized (agent) �� ���''��/If7rL to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) ©�,�(� koAki i �� �y�
at (my property located at) Z
ru,vl,s 6,> Jc-
This certification is valid thru (date)
J,l — lre
60col�

■ Complete items 1, 2, and 3. A. Signature
■ Print your name and address on the reverse X �� ❑ Agent
so that we can return the card to you. ❑ Addressee
■ Attach this card to the back of the mailpiece, B. Received by (Printed Name) C. Dptepf Delivery
or orr the front if space permits. I I I 11 A 111A
Article Addressed to:
Cv'
D. Is delivery address different from item 1? ❑rYe.,
If YES, enter delivery address below: ❑ No
II I'IIIII III'I I II II II II II I III'II II I I II I I I 3. Service Type ❑ priority Mail Express@
ElAdult Signature ❑Registered Mail-
aiIT"'
❑ Adult Signature Restricted Delivery D Registered Mail Restricted
❑ Certified Mail® Delivery
9590 9402 1364 5285 8915 27 ❑ Certified Mail Restricted Delivery ❑ Return Receipt for
rl r)nu—� ^---- Merchandise
2. Article, w'..—._ lestricted Delivery Signature Confirmation'"
7 015 0920 0000 76103939 ❑ Signature Confirmation
nsured Mail Restricted D� liven, Restricted Delivery
(over $500)
PS Form 3811, July 2015 PSN 7530-02-000-9053 Rs Domestic Return Receipt

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual Applying For Permit:
Address of Property:
(Lot or Street #, Street or
(City and County)
hereby certify that I own property adjacent to the above -referenced property. The indiv
applying, for this permit has described to. me as shown on the attached drawing the developmen
Are proposing. A description or drawing, with dimensions, should be provided with this Lett
I have no objections to this proposal.
• ��� � J P P
1
If you have objections to what is being proposed, please write the Division of Cc
Management, 127 'eardinal Drive Extension, Wilmington, NC 28405 or call 910-796.
within 10 days -of receipt of this notice. No response is considered the same as no object
you have been notified by Certified Mail.
WAIVER SECTION
:understand that a pier, dock, mooring pilings, breakivnter,.boat house or boat lift must
bck a minimum distance of 15' from my area of riparian access - unless waived by me.
`Nish to waive the.setback,-you must initial the appropriate blank below.)
I do wish to waive the 1 5' setback requirement.
I do not wish to waive the 1 5' setback requirement.
Sign N m Date
X , #%.\
.,anor-NW-,w.

• DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual Applying I ing For Permit: 1
Address of Property:
(Lot or Street #, Stree or Road)
SAWWAW=m
(City and County)
hereby certify that I own property adjacent. to the' above-referenctd property. The indivic
applying for this permit has described to.me as shown on the attached drawing the development t
are proposing. A description or drawing. with dimensions, should be provided with this letter
I have no objections to this proposal.
If y u have jections to what is being proposed, please write the Division of Coa
Management, 127 'Cardinal Drive Extension, Wilmington, NC 23405 or call 910-796-7
within 10 days'of receipt of this notice. No response is considered the same as no.objectic
you have been notified by Certified Mail.
WAIVER SECTION.
I understand that a pier, dock, mooring pilings, breakwater, boat house or boat lift must b,
bcka minimum distance of 15' from my area of riparian access- unless waived by me. (If
wish to waive the.setback,-you must initial the appropriate blank below.)
1 v I do wish to waive the 1 5' setback requirement.
I do not wish to waive the 1 5' setback requirement.
Y /� , ,, , , , e - — //
1
Sian ame Date
V

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