66650D - Sands

-^LAMA / ❑ DREDGE & FILL A B
NENERAL PERMIT Previous permit#
New El 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
❑ Rules attached.
it Name V V�l Project Location: County i� ; , l
Street Address/ State Road/ Lot #(s)
State 1 {1.ZIP Li��L , N4 t% �i` �A.,
:ed Agent
❑ Cw
❑ OEA
❑ P-WS
yes / no
i , ' ,
-Hail
jEW *TA DES ❑PTS
❑ HHF ❑ IH ❑ UBA ❑ N/A
f Project/ Activity
ick) length
atform(s)
Platform(s) j
iier(s) —
:ngth
tuber
d/ Riprap length
g distance offshore
ix distance offshor
hannel e
bic yards
np
ise/
ulldgEing
e Length
not sure
kttached:
Subdivision
City �:t i;1,. ZIP
Phone # ( ) River Basin
Adj. Wtr. Body l-o n
Closest Maj. Wtr. Body
ng permit maybe required by:
Local Planning jurisdiction)
,;
❑ See note on back regarding River Basin r
�i •

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: Permit #; U Lou
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
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts
FINAL Feet
(Anticipated fina
disturbance.
Excludes any
restoration andh
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Other)k
as
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 ❑

PIMA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis John E. SW
Governor Director Secret
AGENT AUTHORIZATION FORM
Date:
Name of Property Owner Applying for Permit: Name of Authorized agent for this project:
iL-rnhPn�� Sra�✓��
Owner's Mailing Address:
Phone Numbered) -S i Z — b 16 �
Agent's Mailing Address:
YI)R/�S�
Phone Number Cam,,
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):
-e4
605 5 40a /` &/
For my property located at 2 QA
This certification is valid thru (date)
Property Owner Signature Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to l�- zV h<« /r%i :j ,z /g I
(Name of Property Owner)
property located at � � � � � / 5 /,�„�,�' �/,� _
(Address, Lot, Block, Road, etc.)
on .1 /r- P�, �� s �`,rza ! , in L! 'T_ S�� 2 ,:? —, N.C.
(Waterbody) (City/Town 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 fill in description below or attach a site drawing)
7i,5
`l� l WAIVER SECTION Rze/<--A4,C
I understand that a pier, dock, mooring pilings, boat ramp, 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)
Signature
Print nr Tumn AlamA
(Adjacent Property Ow formation)
Print nr Tvnn Namc n

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to X'" '4". AA3,, --� I
(Name of Property Owner)
property located at / 2 46 T5 fdrsc� .4-2N
(Address, Lot, Block, Road, etc.)
on I in �; .2 N.C.
(Waterbody) (City/Town 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 fill in description below or attach a site drawing)
L K l ,qeer5 5
+o �.to��-s"� a
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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)
Signature A
!il i iYl �7f n % a t/ �A.VYA
(Adjacent Property Owner Information)
Si rr +� i
.l 1i1t�