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Home My WebLink About61308D - Suratt NC Pivision of Coastal Mgt. Habitat Impact Computer Sheet Applicant:-Tw Date: Permit #: c!'(2jb� 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. (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/o temp impact amount) V( v Dredge ❑ Fill ❑ Both ❑ Other � k , i Dredge ❑ Fill ❑ Both ❑ Other ❑ l Ld l '-t Dredge ❑ Fill El Both ❑ Other ❑ Dredge, ❑ Fill ❑ Both ❑ Other ❑ Dredge ❑ Fill ❑ Both ❑ Other ❑ Dredge [I Fill El 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 El Fill [I Both El Other [IDredge ❑ Fill ❑ Both 0 Other 171 NC Division of Coastal Mgt. Habitat Impact Computer Sheet Applicant: ��u ��'` Permit##: 5i-SO $�fl Date: Describe below the HABITAT disturbances for the application. All values should match the name, and units of measuremen found in your Habitat code sheet. Habitat 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 FINAL Feet (Applied for. (Anticipated fina Disturbance disturbance. total includes Excludes any any anticipated restoration andh restoration or temp impact temp impacts) amount 0 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 Q Other ❑ Dredge ❑ Fill 0 Both ❑ Other 0 AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION Name of Property Owner Requesting Permit: �/� cX.f!'oa Mailing Address: Phone Number: .3_ &- ,2SD Email Address: JS��Uf/'olif -�rra�� 'f. Orrt I certify that I have authorized Agent / Contractor to act on my behalf, for the purpose of applying for and obtaining all CAMA permits necessary for the following proposed development: l� �M JA at my property located at a %1 & /'dl A in � la)14441 County. l furthermore certify that l am authorized to grant, and do in fact grant permission Division of Coastal Management staff, the Local Permit Officer and their agents to en on the aforementioned lands in connection with evaluating information related to t permit application. Property Owner Information: Signature 411 Al Print or Type Name Title CERTIFIED MAtL RETURN RECEIPT REQUESTED DIVISION OF COASTAL MANAGEMENT ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM Name of Property Owner: Address of Property: g7%/f /j{4 /'P�l (Lot or Street #, Street or Road. City 8_, County) c� >'u Agent's Name #:�ra�Mailing Address: � ) Agent's phone #: /O ' o? j o? - 2- ere y certi t o own property a lacen o e a o le re erence applying for this permit has described to me as shown on the attachea hey are proposing. on scri tior in drawgd dpw ng the development , �t dimension,_ must be bro-ter. _A_/_ 1 have no objections to this proposal. I have objections to this proposal. f 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 /o response is considered the same as n available at http://wryyv.nccoastalmananemenLnet/web/cm�':; taff-listir� or by calling 1-888-4RCOAST. o obiectfon if ou nave been notified by Certified Mail WAIVER SECTION understand that a pier, dock, mooring pilings, boat ramp.. breakwater, boathouse, or lift must e set back a minimum distance of 15' from my area of riparian access unless waived by me. (If m ou wish to waive the setback, you Lust initial the appropriate blank below.) I do wish to waive the a 5' setback requirement. I do not wish to waive the 15' setback requirement. Olroperty,Owner Information) Ignature �nt or 07�ypeNa�me iling Address )((Riparian Property Owner Information) Signature Print or Type Name Mailing Address Complete items 1, 2, and 3. Print your name and address on the reverse so that we can return the card to you. Attach this card to the back of the mallpiece, or on the front if space permits. Article Addressed to: 3� /.I✓es 4vs6la# A&ol n �I N4319 IIIIIIIIIIIIIIIIIIIIilllllllllllllll IIIIIIIIII 9590 9403 0293 5155 8965 41 Article Number (Transfer from service label) :I, ?015 0640 000? 641? Form 3811, April 2015 PSN 7530-02-000-9053 ,omplete items 1, 2, and 3. 'rint your name and address on the reverse o that we can return the card to you. attach this card to the back of the mailpiece, it on the front if space permits. article Addressed to: WC-4 -rtz>j+ ,�,)o Ark Av& Eyk. B. Nq%W !"HntM Name) C. D� D. Is delivery address different from item 1? If YES, enter delivery address below: 3. Service Type ❑ Priority ❑ Adult Signature O Registe ❑ Adult Signature Restricted Delivery ❑ Registe fled Mall® Deliver Cprtifled Mail Restricted Delivery ❑ Return ❑ Collect on Delivery ! Merch. D Collect on Delivery flestricte d Delivery ❑ Signati r7 1,%.k..r-A k/nth ��•, ' "" " it ❑ Restr i 6648 �'�ed DAery Domestic C. D M delivery` address different -from item 1? If YES, enter delivery address below: ITED STAT4AP4 (ct C 4ti t _r 1 First -Class Mail 111111 Postage & Fees 4 USPS v Permit No. G-10 • Sender: Please print your name, address, and ZIP+40 in this box* 1�03�Y jay oqlz- ST j�qii'ij3�1i�iji 9590 9403 0293 5 8 965 41 TED STATESJ� >:�F3,U First -Class ME -_" • Postage & Fe+ USPS Permit No. G- • Senders�a'i5 " print your name, address, and ZIP+4® in this box• as v ") a"- 0��q 43