67125D - Slack

J.CAMA / ❑ DREDGE & FILL Kb- 57n ;' wr
�n J17
A A B
�EN cnAL PERMIT Previous permit #
ew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC C'�
❑ Rules attach
t Name k Project Location: County V�
(Cl Vv Street Address/ State Road/ Lot #(s)
�{ n State ZIPiUE —14�--------- _ _"_ _.--------
() C°i�.�� E-M 'I -'ri Subdivision
edAgent `;'u trCi h (a ZIP
ElWT-CW A ❑ S '❑ PTS Phone (� 1 dU )�� 'ver Basin
❑ OEA U HHF P14H ❑ UBA ❑ N/A
Adj. Wtr. Body Ct VAnat
❑ PWS.
yes /fin j PNA yes / .rfo� Closest Maj. Wtr. Body
Project/
V S �V\
:k) length_
itform(s) _
Platform(s)
igth
nber
i/ Riprap length
,distance offshc
x distance offsh
annel
iic yards
ip
W Boat
Length {�
not sure yes
um: n/a yes V
Yes
attached: ® no
ig permit may be required by:
_ocal Planning jurisdiction) 0 4 ^
I 1 r (Scale:
01 1h ` It"', �(A(. k ❑ See note on back regarding River Basin r

MC Division of Coastal Mgt. Habitat impact Computer Sheet
Applicant: S 1 G t'— Permit* G%
Date: 0-7
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measureme
found in your Habitat code sheet.
Habitat Name
TOTAL Sq. Ft.
(Applied. for.
DISTURB TYPE Disturbance total
Choose One 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
acts
FINAL feet
(Anticipated fit
disturbance.
Excludes any
restoration an(
temp impact
amount)
v 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 ❑

��
r.
NCDENR.
North Carolina Department of. Environment and Natural Resources
Division of Coastal Management
ieverly Eaves Perdue James H. Gregson
governor Director
AGENT AUTHORIZATION FORM
Date: 7// 3
) - /.-
ame of Property Owner Applying for Permit:
J'� 94
wner's Mailing Address:
a �r
` L4
hone Number (3►S) . 5Q -- 4w a(o.
Dee Freema
Secretar
Name of Authorized Agent for this project:
� 5 , J_ NC
T
Agent's Mailing Address: "�1yC w
00 IAA -�6:ctc-k �� C
a�y�a
Phone Number (910) <�qa (oo(c
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
)r and obtaining all CAMA Permits necessary to install or construct the following (activity):
��A� Rce �xtsri�uG ace X g Dbc,k Alu 2)aa (,�/ 11/rvAy
X i 5 7"/ N G To�%
ny property located) at � �/C� J/�l n off% I` J t - °too a
'his certification is valid thru (date) /
Prnnnrty nwner Signature Date

/2016 14:51 FAX [phone] CH Sports Medicine IM0002/0002
IL —
CERTIFIED Mi All, RETURt�1REGEII''x EQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY O'kNER STATE11E1`C"T
Iamc of Property Owner: 'G� L
.ddmss of Property
{Lot or
pplicant's phone 4, 9,n �E,%„ LQz_
(e-tf- 1Y0/CVL0K, � PAC I-7
'.reet #, Sttreet or Road, .City & County)
Mailing Address: Cs7
hereby certify that;I°own property adjacent to the above, referenced, property. The individual applying for this permit
is described to me as..shown oil the attached ftwing the development they are proposing A deacrintion.ofdrawigg.
ith.dimensions, mustbe provided with.this letter.,
~I have -no objections to this proposal. I have objections to this proposal.
you have objections to w:hat,is'being proposed:, you: must notify the Division of Coastal Management (D.C1VI)
ioriting ixithin 10 days of receipt of tbis.itotice. Correspondence should be mailod to 127 Cardinal Drive Ext.
�ilmigbton, NC 28405-3845. DCM representatives -can also be contacted at (910) 7%-7215. No response is
msidered the.same,as no ohkction if you have been notified by Certified Mail.
WAIVER SECTION
!gdeistand. that,a.pier, .dock, mooring,pilina , brealcw ter.,;boatbouse, or Jt#t must beset back a rmnimum distance of
from my area of -riparian -access unless waived by me. (If you wish to waive the seiback,.you must initial the
proprive blank below)
? I do wig to waive the 15' setback requirement.
I do notwish to waive the 15' setback requirement.
rope OwnerInformati ) "p;rrianProperty Owner Information)
gnatur ��t� Scga re
(AJ
int or Type Name Vfflwor Type Name
C�C7�A�,�,�ItY1 �1 cio L � cty
ziliiig Address . arN AriCh•ege

7'ey —
CERTIFIED MAIL — RETURN RECEIPT .REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner:
>
/
Address of Property: q�p
n (I,ot or Street #, Street or Road, Cityj& County)
Applicant's phone 4: 91v 0pI7 0� 0& / _ Mailing Address: �32 &5!5 4ltl
Ph �-'� �� /U Y /3 /35
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this porn
has described to me as shown on the attached drawing the development they are proposing. A description of drawin
with dimensions, must be provided with this letter.
0I 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 clays of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ex
Wilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the -same as no objection if you nave 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 distance e
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' set back requirement.
I do not wish to waive the 15' set back requirement.
(1'roperty Owner Information)
G
Signatu
Print or T pe Name
-le,& a7eAtu' &VC1 w
(Riparian Property Owner Information)
1�
Signature
Print or Typ6 Natne
1832 Wyso,%y Ct
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