66597D - Poole

�CA;r / DREDGE & FILL " �'' ��
aE�RAL PERMIT Previous permit # A B
ew CJModification ❑Complete Reissue El Partial Reissue Date previous permit issued
¢ed by the State of North Carolina, Department of Environment and Natural Resources i +
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC j (a
D p ❑ Rules attached.
t Name Lowe We � � `�0 Project Location: County
{ r, Street Address/ State Road/ Lot #(s)
State ZIPr�� 1 'y a- Y 1 j+
(33b) 5�1 (1 De E-Mail Subdivision
ed Agent t�Ccl.h vrq t 4kig ce4mobil City �O ZIP
❑ Cw ❑ EW ❑ PTA KES $(PTS Phone # (3S �) 4 q ^ N ", g b River Basin L Y
❑ OEA ❑ HHF ❑ IH �❑ UBA ❑ N/A
Adj. Wtr. Body C in 61 n
El PWS.at
yes / �0 1 PNA yes / (o)Closest Maj. Wtr. Body
Project/ Activity _
ck)length
itform(s)
ngth /
nber
� iprap length
�istance offshore
x distance offshore
cannel
A" &\ -- ),d xS0'
Length
notsure yes
cum: n/a yes
yes
atached: yes
M
(Scale: 1"
ig permit may be required by: �py�A1 0 T �` (�,�j� ��(� ❑ See note on back regarding River Basin r
_ocal Planning jurisdiction)

NC Division of Coastal Mgt. Habitat Impact Comi
Applicant: 1-ow-0-0
Date: 0 `�o-7/' -O ( U
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
FII
(Applied for.
(Anticipated final
(Applied for.
(Ar
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
dis
Habitat Name
Choose One
includes any
Excludes any
total includes
Exi
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
ten
temp impacts)
impact amount)
ternimpacts)
arr
Dredge ElFill r4 Both ElOther ElI
V 00
00
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
Name of Property Owner Requesting Permit. -
Mailing Address:
Phone Number: - 9 _ Lt7 OC)
Email Address:
I certify that I have authorized, n�
Agent !Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
in _�Uu; �.� County.
l furthermore certify that l 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
Ci�ua l t moo' o !r
Pr* or Type Name
TNe

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner'. �,Owe-\\ - o0N e
Address of Property )l .14
(,Lot or Street W, Street or Road City & County)
Agent's Name #: -r->e,,A
MailingAddress.
Agent's phone # 'AABO
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 drawingjhe development
they are proposing A description or drawing, with dimensions, must be provided with this letter.
�Jhave 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 Na"gement(OCAf) in
writing within 10 days of receipt of this notice. Correspondence should he mailed to 127 Cardinal Drive Ext.,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no oMection it YOU have been notified by Certified it
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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 rnust initial the appropriate blank below.)
QCI I do wish to waive the 15'setback requirement.
I do not wish to waive the 15'setback requirement,
(Property Owner Information)
Signature
/ nVie-11% *—PDA
Print or Type Name
116 4,41-
, 't ,
Mailing Address
n lecla
(Adjacent Prope Owner Information}
Signature
(� t3
Print or Type Name
k r�v
- A -�-
Mailing Address

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONfWAIVER FORM
Name of Property Owner: �well 20�e-
Address of Property, Loll x ar 9 () .'N --
12:t,
(Lot o, StreetV Street or Road
coy & County)
Agent's Name #: Mailing Address.
Agent's phone #:
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 drawin_q, with dimensions, must be provided with this letter.
I have no objections to this propo."]. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division or Coastal management(OCU) In
writing within 10 days of receipt of this notice. Correspondence should be matted to 127 Cardinal Drive Ert.,
Wilmington, NC, 28405-3845, DCM representatives can also be contacted at [phone], 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, breakwater, boathouse. Ifft, or groin must be set
back aminimum 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
I do wish to waive the 15'setback requirement,
fdled
1 do not wish to waive the 15'setback requirement
(Property Owner Information)
Polk
Signature
Z6 UJ e / I
Print or Type Narm
I 16 — /.4 Ap X c,
Mailing Address
(Adjacent Property Owner Information)
signalt$4�
Print or Type Name
Mailing Address
1'ifu11Ctn1=J7,'n
Raj,= - C-1