67933D - Rackness

NC Division of Coastal Mgt. Habitat Impact ComF
Applicant: w ka L�
Date: 1 Z Z/20 :?
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
FIN
(Applied for.
(Anticipated final
(Applied for.
(Anl
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disti
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
rest
restoration or
and/or temp
restoration or
tern
temp impacts)
impact amount)
temp impacts)
am(
Dredge ❑ Fill Both ❑ Other ❑10
O V f
Dredge ❑ Fill Both ❑ Other ❑
Z 00 0
Z 000
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge 0 Fill ❑ Both ❑ Other ❑

'ayment Proccessing Confirmation
late Received 11/9/2016
heck From (Name) Clements Marine Construction Inc.
lame of Permit Holder Gary Castleman
Fendor First Citizens Bank
:heck Number 4238
heck amount $800.00
►lultiple Permits Yes
►lajor/Minor
'ermit Number/Comments GP 67932D
receipt or Refund/Reallocated JD/3401D

From: Rockness, Joanne
Subject: new doc 12
Date: Oct 20, 2016011:03:47 AM
To- [e-mail]
Letter of agent
I have retained Mark Clements DBA, Clements
Marine Construction Inc, to make application for any and all permits needed to start
construction on the work requested for our property or properties.
By allowing Mr. Clements to make such applications I do understand that this will in no
way relieve me of any obligations to perform all work according to the building codes of
North Carolina, CAMA, DWQ or any other state and or county ordinances.
Print
7
Si re
date ! Contact information

From: Rockness, Joanne
Subject: new doc 11
Date: Oct 20, 2016, 11:03:26 AM
To: [e-mail]
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to r ,of Property
O -rs
/ - (Name of Property Owner)
Property located at _ 1 ' � 1°c�[�—
(Addre s, Lot, Plock, oad, etc.
on �� %/►h� . in , /i/.t �/il��n �i✓ �%A/l�!/</ N.C.
(Waterbody) ity/Town and/or County)
The applican as 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 ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
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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.

(Waterbody) (city/Town and/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)
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ro ax' AR tYI f
l a r-° , -
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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 setback requirement.
I do not wish to waive the 15' setback requirement.
(vroperty owner nformation)
(Adjacent Prop"- near Information)
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Print or Type Name
Mailing Al
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Mailing Addrg�ss
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City/Sta a/Zip
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City/state/Zio
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Telephone Number / email address
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Teleph ne Number/email address
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