66593D - Spivey

ICAMA / ❑ DREDGE & FILL
31ENtERAL PERMIT
}New ❑Modification ❑Complete Reissue
j'�� �\J� � � �O
❑Partial Reissue
A
Previous permit #
Date previous permit issued
B
Ized by the State of North Carolina, Department of Environment and Natural Resources
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
t Name C��iri/P I {mil Project Location: County AJ�',�/7�`
d'g, 17, ArX 2 Z Street Address/ State Road/ Lot #(s)
%Wi� StateAte ZIP__ % Ly �� F`.,. le /-/I .
(�b '} E-Mail Subdivision
ed Agent ) olphk G✓ f CiZIP'////1111
❑ CW �;9;W 2n A ❑ ES ❑ PTS Phone # ( ) %& River Basin
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ N/A Adj. Wtr. Bod(nat it
❑ PWS: IQ
es / no PNA yes /(5) Closest Maj. Wtr. Body
'froject/ Activity
_1ShGlletIII
:k)length
ttto
atform(s)
ier(s)
ngth
nber
i/ Riprap length
;distance offshore
x distance offshor
cannel
sic yards
np C-
s oath 1 J %C 11
e Length i
not sure yes 09
ium: n/a yes
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ng permit may be required by: __Z
Local Planning jurisdiction)
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❑ See note on back regarding River Basin r

SIC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: �GG�' 1"1 N ye Permit #:
Date: '5-12S /4
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
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(App►ied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet FINAL feet
(Applied for. (Anticipated final
Disturbance disturbance.
total includes Excludes any
any anticipated restoration and/c
restoration or temp impact
temp impacts) amount)
(/ 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 ❑
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 ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other 0

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
McCrory Braxton C. Davis
Dvernor Director
John E. Skvarla,
Secretary
AGENT AUTHORIZATION FORM
Date:
ie of Property Owner Applying for Permit: Name of Authorized Ag t for this project:
r �
i is Mailing Address:
{O qG;t--1
ie (S/a ) 9.5 1 — /5/(e 0
Agent's Mailing Address:
Email:
Phone
tify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Permits necessary to install or construct the following (activity):
my property located at to lid E c La,-0 G
certification is valid 1 year from (date)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to S
property located at (Name of Property Owner)
(Address, Lof Bloc , Road, a c.)
on _ t� in , N.C.
(Waterbody) (City/T n 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 rill in description below or attach a site drawing)
9 P �
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 must initial the appropriate blank below.)
do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
L
tature Si ature
I
R
t r T pe a e Print or Type Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ,s
property located at �� ( ame o Prope Owner)
on WO (Address, L' t, Block, Road, eT�n.
(Waterbody) in
, N.C. (City/To 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)
X� " I'l o 3'R 4(6 (
q 4-V g1 04i0
h0'pct I '++
1-1 dock.
A rz( 'Z� �)' 1ICT
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 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)
C .
nature
A
(Adj11 ac P operty Owner Inform on)
c �;� 1
1
Signature
Pnn�t�or.�Ty- e N(a/mbn
L IL 1 1 n 1 N N A Al-e I
Pr' t or Type am //)