66260D - Surratt

I CAMA / ❑ DREDGE & FILL Yi V 117 A B
"ENERAL PERMIT Previous permit#
*ew ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
t ❑ Rules attached.
t Name TWe4 No/Va�_ Project Location: County `✓ )0.2 •�
Street Address/ State Road/ Lot #(s)
State ZIP
�� ���•(,
(�1LY-Mail Subdivision
ed Agent VA
City ZIP �'
❑ Cw ❑ ES ❑ PTS Phone # ( �� River Basi t
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ WA �
Adj. Wtr. Body VI Y\t- nat r
❑ PWS:
t
yes t no / PNA yes no Closest Maj. Wtr. Body
Project/ Activity
.. . . , l `e i — 11
(Scale: I K 2,

IBC Division of Coastal Mgt. Habitat impact Computer Sheet
Applicant: C���-�-
I
Permit #.
Date:
[2*1�
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
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/or
restoration or
and/or temp
restoration or
temp impact
temp impacts) impact amount) temp impacts) amount)
�J Dredge ❑ Fill ❑ Both ❑ Other u t 1
Dredge ❑ Fill ❑ Both ❑ Other
1 c c�
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 ❑
1 Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other 0

3ayment Proccessing Confirmation
Date Received I —— 12/21/2016
heck From (Name) Allied Marine Contractors LLC
Name of Permit Holder Todd Surratt
Vendor
Check Number
Check amount
Multiple Permits
Major/Minor
First Citizens Bank
5134
$200.00
No
Permit Number/Comments GP 66260D
Receipt or Refund/Reallocated TM/2803D
C-

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: T=�
Mailing Address: A/�, '&Y
vnrz-
Phone Number:'
Tay
Email Address:
I certify that I have authorized ,
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaini
ng all CAMA permits
necessary for the following proposed development: "
at my property located at
in - e County.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Print or Type Name
itle

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER//NOTIFICATIONIWAIVER FORM
Name of Property Owner: �d4 5ei ff4 /-
Address of Property:
E
or Street #, Street or Road, City & County)
Agent's Name #: lNicj �Gl;/�C, Mailing Address: / 14�­l C-
Agent's phone #: 9��J'o? -o�S� /�ampSev
�,
hereby certify that I own property a lacent to the above referenced property. a in ivi ua
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions, must be provided with this letter.
Y I 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
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at http://www.nccoastaimanagement.netlweb/cm/staff-listing or by calling 1-888-4RCOAST.
No response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift must
be set back a minimum distance of 15' from my area of riparian access unless waived by me. (If
you wi h to waive the setback, you must initial the appropriate blank below.)
r-", I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
fd
Print or Type Name
P.o- A ox P)2) S
(Riparian P�o"rty Owner Information)

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNERLLI1NOTIFICATION/WAIVER FORM
Name of Property Owner: [o—d) 5a fI q'`/-
Address of Property:
(Lot or Street #, Street or Road, City & County)
Agent's Name #: 1.)1l i') Mailing Address:
Agent's phone #: ",-�)3Q) o7Sk� Yam n; {,).
hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they 77:
ng. A description or drawing, with dimensions, must be provided with this letter.
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
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at http://www.nccoastalmanagement.netlweb/cm/staff-listing or by calling 1-888-4RCOAST.
No response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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 Own Information)
Signature
z�,JJ Sabo
(Riparian Property Owner Information)
Signature
Print or Type Name
pC} 80K
Print or Type Name

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