62602D - Sheperd

N`�
-1,rAM/� / --, DREDGE &FILL I�
EN ERAL PERMIT Previous permit #
_jNew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources ' } i zoo
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
t Name Rules ttached. Project Location: County f '
{r i A4 Y c Street Address/ State Road/ Lot #(s)
OL t �,��i i State_ ZiP ' i. l 4L
# O� Fax # ( ) Subdivision
ized Agent City �-- ZIP
d CW L ; EW ❑ PTA ❑ ES ❑ PTS Phone # ( b) River Basin
OEA HHF IH ❑ UBA C N/A Adj. Wtr. Body nat
PWS: ❑ FC:
yes / no PNA yes (no Crit.Hab, yes no Closest Mai. Wtr. Body
MiwvHP
A Project/ Activity
ock) length
ength
umber
ad/ Riprap length
✓g distance offshore
iax distance offshon
:hannel
jbic yards
LmP NY
use/ Boatlift ' X
Bulldozing
ne Length _
not sure yes 'no 4—
gs: not sure yes no
,rium: ,:' n/a � yes no
yes
Attached: yes nod
ling permit may be required by:
(
N"4 f1 N U&l t11J'((! aEl See note on back regarding River Basin i
i-7n�� h 4/1 Al -)AAJ 1r7/,1 f4-s11 11ua 1,.1:.-,.i ur1. _.1 _y

C Division of Coast2i Mgt, Habitat impact Computer Sheet
>plicant: � Permit #.6�4)6.Z
ate: �
:scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
�bitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied 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
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
V
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 ❑

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w���
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
McCrory Braxton C. Davis John E. Skvarla,
)vernor Director Secretary
AGENT AUTHORIZATION FORM
Date:
ie ofProperty Owner Applying for Permit:
:?LeJe Sk t e.164
ier's Mailing Address:
I 10 5 aqe ( br
0/,���, 7��, 961ia51,
Name of Authorized Agent for this project:
Agentt's Mailing Address:
Email:
Phone (Q/L) 3 / - S' S
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
certification is valid 1 year from (date)
c
3 Zi

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to A'o /)"p % L2— ,s
(Name of Property Owner)
property located at /la 3 ei 11(4WL. 1p _
(Address,
(Waterbody)
(City/Town and/or County)
N.C.
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 flit in description below or attach a site drawing)
��(�T i,•i �9 /30� T
$ � 5C (ST/P f
pD
�d5
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.
greOwner Inf rmation (Adjacent Property Owner Information)
�2 Si a e
�7 /2`/ti�
Print dr T)pe Name Print or Type Name
//oS I/4,1 r- 4xlw L- Pz-
Mailing Address Mailing Address _ - , �0 e

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that 1 own property adjacent to �I� r%/ %�/
s
(Name of Property Owner)
property located at i_L> 17 <� . AZd L D7z _
(Add , Lot, Block, Road, etc.)
on %2-k R -i f % N.C.
(Waterbody (Ci yRo�wn 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 DRAVANG OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to waiv
the setback, you must initial the appropriate blank below.)
1 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)
i` e
Signature
rLa�C'L
NEn_ t�Name Print or Type Name
/XL 7 (—W ;W zz 72
Malone Address _ _ /