66538D - Shawver

CAMA / ❑ DREDGE & FILL t��
L/ I (� A B
`
iENERAL PERMIT5191Y
Previous permit #
14ew ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
zed by the State of North Carolina, Department of Environment and Natural Resources
:)astal Resources Commission in an area of environmental concern pursuant to 15A NCAC ; F-1 Rules attached
r
Name N W-\ Y � V~' � Project Location: County —4i'\/4'\�M- C �--
0 ' Street Address/ State Road/ Lot #(s)
✓�G\ StateZIP�� ; I � y M f'�f1'Y� IJ c
(7ZA) ) E-Mail ( __ Subdivision L
;dAgent V�lA � 1/VC) City�' �� � d��r�( �/� ZIP
❑ cvlr Ew 4TA El [IPTS Phone # ( ) River Basin L vr/vl
❑ OEA HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body r V NCA (nat /p
❑ PWS: I I A l I n 1
Closest Maj. Wtr. Body _T
Yes /
Project/ Activity
ck) length
itform(s)
rnum: n/a yes _ _......_
yes gn
Attached: no yes , ' 1 ��1
Jing permit may be required by: -ToVv 1 '
I nral Planning lurisdiction) -) . -- I _ I
(Scale: I "
❑ See note on back regarding River Basin

NC Division of Coastal Mgt. Habitat Impact Com
Applicant:
Date: O
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.
(Ai
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
di:
Habitat Name
Choose One
includes any
Excludes any
total includes
Ex
anticipated
restoration
any anticipated
re:
restoration or
and/or temp
restoration or
ter
temp impacts)
impact amount)
ternimpacts
arr
Dredge ❑ Fill ❑ Both ❑ Other
(
l
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge 0 Fill ❑ Both ❑ Other ❑

ivorui uaroima uepartmeni or tnvironment ana Natural KesourMs.
Division of.Coastal Management .
Beverly Eaves Perdue James H. Gregson Dee Freeman
Governor Director. Secretary.
AGENT AUTHORIZATION FORM
Date:
Name of Property Owner. Applying for Permit: Name of Authorized Agent for this project:
m SA o-wi � 1 � I l J' �-VLtm
Owner's Mallfng Address:
c?
Agent's Mallfng Address:
Phone Numberyt �fU / ". � Phone Number @i0 ) -� ��j
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits neces!ary to install or construct the following (activity):
�-- I i � , I — ► 11
(my property located) at
This certification is valid thru (date)
Property Owner Signature Date
127 Cardinal Drive Ext., Wik"On, NC 20405 ne ��11 , - -
on. „e• oil 7qR 791A 1 FAX- A1ww0-3954M InWel: wwonialmanagemenl.net �P...u�C'$TOp�.,a.

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR APIEXMOORINGPLUArGSBOAT UT/B OATSOUSE)
I hereby certify that I own property adjacent to )
Ne�oProp�e��
.m
Owner)
Property located at )
.(Lot, Block, Road, etc.)
on
is c i� ld `t�r�� c
� �.,._ N.C.
(Waterbody) (Town and/or County)
Applicant's phone f1 &7 # % - � . S' t/ M$Ring Adares: s1 + +
He has described to me, as shown below, the development he is proposing at that location, and, I
,bavc no objections to his proposal. I understand that a pier/nmring piliugs / boatli$ / boathouse
must be set back a minimiun distance of fifteen feet (15) from my area of riparian access unless
waived by me. (If you wish to waive the setback, you must initial the appropriate bl nk
below.)
I do not wish to waive
I do wish to waive that setback requirement.
DESCRIPTION APrD/OR DRAWNG OF PROPOUD DEVELOPMENT:
b
(To a frlled rn by fisdlvuLival proposing develoDrrce=
(Information for Property Owner Applying pu P Y` -
for Permit) A r ply Owner InformMom)
Mailing Address
2
city to p
`� (�
og—
Prim Type Name r

ADJACENT RIPAX&N PROPERTY OWNER STATEMENT
T'T
(FORA PIE.8,400BING PLUNGSIB0A7LLFTIB0ATH0US-7)
I hereby certify that I own property adjacent to ,' m _1'.h--��•1
{iV ame oProperty Owner)
Property located at
(Lot, Block, Road, etc.)
on ��� , in At),1G `a,ti—��� e�-r, , N.C..
(Waterbody) (Town and/or County)
i�--.5� - d G��i �l Mailing Address:
CLA
Applican#Ys phone �
#:
He has descx-bed to me, as shown below, the development he is proposing at that Iocation, and, I
have no objections to his proposal. I fmderstandthat a pier/mooring pilings I boatliit I boathouse
must be set back a minimmn distance of fifteen feet (15`) from my area of ripa6m access finless,
waived by me. (If you wish to waive the setback, you must initial the appropriate blank
below.)
I do not wish to waive
I do wish to waive that setback requirement,
Al • ESCRIl'TION APt-DIOR DRAWING OF PROPOSED DE)ELOPMENT:
D
(To be
jiiilled in ibyi individual proposing develapm nt)
C&d' 'A
�S
(Information for Property Owner Applying
for Permit)
:�_') c:C'rAc�"��,�
Mailing Address
Information)
Sigriatare
ticit —�� Print or Type Name l

Canal
I II II
8x16 Float
Proposed Boat Lift
13X13
I I
A
LI IN EA
Existing Structures II
II0 ft
I I
F11
I I
8x16 Dock (I II
II II II