67110D - Smith

CAMA / ❑ DREDGE,& FILL ,'^"
3ENERAL PERMIT I I Previous permit #
7New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
sized by the State of North Carolina, Department of Environment and Natural Resources �i I t
Zoastal Resources Commission in an area of environmental concern pursuant to I SA NCAC �7 '
``.� ��' El Rules attached.
t Name l7✓ . Project Location: County /�Kd7/
-7� rvyrS N Ke
qq/''1��'►K'►IhGi�Pn State ZIP 74V/I
( 1 101 'W311 E-Mail
:ed Agent 1
❑ CW W4 ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ryes `- no PNA yes / X-C)
f Project/ Activity
,Y .
ck) length_
atform(s) _
Platform(s)
ngth
tuber
d/ Riprap length_
distance offshore
uc distance offshor
cannel 1
Dic yards
np _� c
ulldozing
e Length �I hh,
not sure yes
i
Street Address/ State Road/ Lot #(s)
/
Subdivision/ .tom
City �/t/l `h�*� *h ZIP
Phone # River Basin
Adj. Wtr. BodyS hL nat
Closest Maj. Wtr. Body r1i
l A'
/
wm: n a yes _L_.....:. i
--
yes Q0
>ttach Oe no
ng permit may be required by:t-
Local Planning jurisdiction)
(Scale:
❑ See note on back regarding River Basin rt
d

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date ` (O
Name of Property Owner Applying for Permit:
Mailing Address:
Z// A/' &Y /IIP
zhll; '!71i7,a )/Da . /y C. ,
wi�1,01441
I certify that I have authorized (agent) �/''//D to act on my
behalf, for the purpose of applying for and l obtaining all CAMA Permits necessary to
install or construct (activity) 90� Z/ 00
!� A
at (my property located at) T Z &,�ep s /V e
ff
This certification is valid thru (date)
Property Owner Siinatuie ` Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ��v s
(Name of Property Owner)
property located at 14 P N e,s lV ec K Ri
t f (Address, Lot, Block, Road, etc.)
on �tLtI�S-L�����« 1 , in /t'�� it e-_,,ot er' �c�c`�, �y N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
L, 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)
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.
E I do not wish to waive the 15' setback requirement.
(P,rIDpjerty Ow Information) Information) (Adjacent Property Owner Information)
Signalur _ _ �.. S�nafure
(-Af J= _ >M i 1 f-1 Y'i i7 e,rr L --eti
Pn or Type"tame Print or Type Name
2.S* I) r

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
.1 hereby certify that I own property adjacent to
property located at 4 / �%P'r- ?-5
��� C Pameoperty Owner)
Address, Lot, Block, R x4o
, etc.)
on 40 , in /001 N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location
= 1 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)
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.)
A_J 1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(P erty Own Information) (A ent Prop O�r Information) ,
_
\)alw
Sj*gnatur 7 ature
Print or Type Name Print or Type Name ,
c- :7 �

NO Division Of Coastal Mgt. Habitat Impact Computer Sheet
Applicant; Pei1711t
Date:7#4
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
I 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)
Dredge ❑
Fill ❑
Both ❑
Other [
Dredge ❑
Fill ❑
Both ❑
Other 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 [IFill
ElBoth
❑
Other [I