66644D - Rooks

❑CAMA / ❑ DREDGE & FILL
ENERAL PERMIT Li7� Previous Permit# A
❑New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
orized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission irran area of environmental concern pursuant to I SA NCAC
Kules attiched.
ant Name ► I/ i GY�I` 5 _ Project Location: County R-1, I ' t
Street Address/ State Road/ Lo #(s)
9,
f State ZIP
77` 3 3 _Mail � '-��a �"��^""'- - rj`"r /. Subdivision
r5
ized Agent f City ��' �i� ZIP
i
d ❑ CWr � �S ❑ PTS Phone # (--'�j'River Basin e,
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ WA Adj. Wtr. Body 1)4,411A1V> &t 64A na
❑ PWS:
yes / no PNA yes no Closest Maj. Wtr. Body
:A Project/ Activity c
lock) length_
Platform(s)
ig PlatformW _
oier(s) .
length
camber
a g distance
length
wg distance offshore �
nax distance offshore
channel
`ubic yards
amp,,
Ouse/ 89atlift
Bulldozing
line Length
not sure yes
orium: n/a yes
s: yes
r Attached: yes
(Scale: I "
ding permit may be required by:
e Local Planning jurisdiction) ( ( I
❑ See note on back regarding River Basin
I

NC Division of Coastal Mgt. Habitat impact, Computer unees
��%
Applicant: 'V
" �n
Date: r l
lV . 1 /
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.
for.
FIMAL Sq. Ft.
(Anticipated final
TOTAL Feet
(Applied for.
Fit
(Ar
DISTURB TYPE
(Applied
Disturbance.totai
includes any
disturbance.
Excludes any
Disturbance
total includes,
dis
Exi
Habitat Name
Choose One
anticipated
restoration
any anticipated
res
restoration or
templimpacts)
and/or temp
im act amount
restoration or
ternim acts
ten
am
a /
� ❑ Ot
!/f Lim
t
Dredge ❑ Both
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge []
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
DredgeEl.
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other 171

AGENT AUTHORIZATION FOR LAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address: 164 y M A-11
Phone Number:
Email Address: 610'1 a-r4� %, lo�,s��� �4Z I 4go..07-�
certify that I have authorized n L° i
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:�Z
at my property located at Z65 y ���rcY d /Y /W
in <�,,,�Pi County.
1 furthermore certify that 1 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:
4�Z,4w-,
Sign ture
Print or Type Name
IZ& A I/
Title

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: t9
Address of Property: `l of ./UfL 4#,rl v 154 y /fib 111WArr.
(Lot or Street #, Street or Road, City & County)
Agent's Name #: X 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 drawing with dimensions must be provided with this letter.
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 httpJ/www.nccoastalmanagement.net/web/cm/staff-listing orby 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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback. requirement.
(Property Owner Information)
Signature
Print or Type Name
IO C-/Lf XAIALL/s #en i3A%r APn
10"
pe wnerrinformation)
Si ature
r,
bAEV
S
Prnt or Type ffame /�

CERTIFIED MAIL • RETURN RECEIPT RECIUSTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:
((Lot or Street #,
Agent's Name #:
Agent's phone #:
or Road, City ✓3< 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 drawingthe development
they are proposing. A description or drawing with dimensions must be provided with this letter.
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;llwww.nccoastalr»anaQement. net/web✓cm/staff-//sting or by calling 1-888-4RCOAST.
No response Is considered the same as no objection If you have been notified by Certifled 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.)
do wish to waive the 15' setback requirement.
{J-
} I do not wish to raive t e 15' se req item t. �,,�
Signature
Pr7nt o Type Name
/P-(/ Y Afaliel Wd
11. ;K..- w -_ _- 'ice
(Riparian Property.pwner Information)
)Signature 1
Prriin7t or Type Name
C
4

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