66586D - Salone

ICAMA / ❑ DREDGE & ALL �Ij //673ENERAL PERMIT Previous permit #
Alew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
prized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC ��`t
r� U
❑ Rules a shed.
it Name �Ao � i b r1 t, Project Location: County ��S �t 1(
P• `� R D y C� � bCO Street Address/ State Road/ Lot #(s)
0' l �y State_)'j� ZIP
(10) 3 1v0'6G E-Mail _ Subdivision
Eed Agent Ck v City 5 h �\ \�O�C. ZIP -A
❑ CW '$EW .PTA ❑ ES ❑ PTS a ��� Phone # ( ) River Basin LW
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ N/A Adj. Wtr. Body Sly I 1 ok 6, - 4a /
❑ PWS:
yes / - no.' PNA ye / no Closest Maj. Wtr. Body
F Project/ Act'vity
,ck) length
atform(s)
Platform(s)
iier(s)
:ngth
tuber
d/ Riprap le
g distance off ore
. distance o shore
cannel
bic yards
e Length -
not sure yes no
ium: n/a �y`eess no
l� o
kttached: yes n�
ng permit may be required by: -1M S v1❑ See note on back regarding River Basin n
Local Planning Jurisdiction)
(Scale: ri ,

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: (%I t) ` oV�2 Permit
g
Date: I /�
Describe below the HABITAT disturbances _for -the appllcation._AII_val_ues should match the name, and units of measurement
found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
Habitat Name
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/oi
restoration or
and/ortemp .
restoration or
temp impact
(�) I Dredge ❑ Fill ❑ Both ❑ Other I (Q I 5 & 0 I I
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 ❑

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
Dee Fre
Sec
AGENT AUTHORIZATION FORM
Date:_
Name of Properly Owner Applying for Permit: Name of Authorized Agent for this project.
%
Owner's Mailing Address
Phone Number �1-3
Agent's Mailing Address.
lei f2l
'w
0
Phone Number (9'/4)) MY
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 necessary to install or construct the following (activity):
�l ./J I , .
(my property located) at
This certificatio i hru date)
Property Owner Signature
4/-
Date

CERTIFIED MAIL — RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner: Ct U a Oz/
Address of Property:
(Lot or Street #,
Applicant's phone #: - yY3
ve & 1 r
or Road, City & County)
Mailing Address: ri " 3
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
has described to me as shown on the attached drawing the development they are proposing. A description of dr
with
thdim ons must be provided with this letter.
�Kh e no o iections to this proposal _ _ _ I have objections to this proposal.
d2vu
If you have objections to what is being proposed, you must notify the Division of Coastal Management (I
in writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Dri,
Wilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No respons
considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be setback a minimum dist,
15' from my area of riparian access unless waived by me. (if you wish to waive the setback, you must initial
appropriate blank below.)
I do wish to waive the 15' set back requirement.
I do not wish to waive the 15' set back requirement.
(Property Owner Information)
Signature p
Print or Type Name
Mailing Address
(Riparian roperty Owner Information;
Sign ture
Print or Type Name
Mailin� Address B
City / State YZiP I/-
TPiPnhnne Number
City / State / Zip
Telephone Number

CERTIFIED MAIL — RETURN RECEIPT REQUESTED
DIVISIOiti OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner: JJ� U
Address of Property: 9 3,J4�
r / (Lot or Street #,
we s
or Road, City & County)
1L �
Applicant's phone #:=7 Mailing Address:
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this
has described to me as shown on the attached drawing the development they are proposing. A description of dr
with dimensions, must be provided with this letter.
\ 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 (I
in writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Dril
Wilmington, NC 28405-3845. DCM representatives can also be contacted at (910) 796-721& No respons,
considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be set back a minimum distr
15' from my area of riparian access unless waived by me. (If you wish to waive the setback, you must initial t
appropriate blank below.)
1 do wish to waive the 15' set back requirement.
I do not wish to waive the 15' set back requirement.
(Property Owner Information)
Signature /
Print or Type, Name
d 2✓"
Mailing Address
,l Z Z��
City / State AilS le
Q
(Riparian Property Owner Information)
L
Signa
,/s_ „ / C/1 t� c
Print or Type Name
Mailing Address
City / State / Zip

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