66687D - Thomas

I.CAMA / ❑ DREDGE & FILL
GENERAL ` { A B
PERMIT Previous pgf-mit #
7 ew El Modification ❑Complete Reissue artial Reissue Date previous permit issued
riized by the State of North Carolina, Department of Environment and Natural Resources —7
-oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC I �� I{�
Rules attached.
it Name �'� � ���i j I � i���� Project Location: County
t
I U 1 C1 �- In L a � Street Address/ State Road/ Lot #(s)
1
state Zip �C 'A St
E-Mail '�— _ Subdivision
Eed Agent
❑ CW A EW
Xi PTA ❑ ES
❑ PTS
❑ OEA ❑ HHF
❑ IH ❑ USA
❑ N/A
❑ PWS;
yes / ono PNA
yes / no
f Project/ Activity
J f �.-
Kk) length
latform(s) O
-
angth
amber
Id/ Rip length_
g di ce offshore_
ax d tance offshore
city Kr�� W ZIP '1
Phone # ( �� �~ River Basinn �Vu
Adj. Wtr. Body (� �� r at
Closest Maj. Wtr. Body
A
V-A Da'H
(Scale: j � \ --
1
❑ See note on back regarding River Basin i

NC Dives on of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: �a 110 Permit #. & �(9 S'7 -
Date:
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
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 Fed, FINAL Feet
(Applied for. (Anticipated final
Disturbance disturbance.
total includes Excludes any
any anticipated restoration and/o
restoration or temp impact
temp impacts.) amount)
t ,
Vv
Dredge ❑ Fill ❑ Both ❑ Other Qb
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge,[] Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both El Other ❑
Dredge ❑ .Fill ❑ Both ❑ Other EI
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 0 Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

AJ�A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
it McCrory Braxton C. Davis John E. Skvarle
aovemor Director Secretary
AGENT AUTHORIZATION FORM
Date:
me of Property Owner Applying for Permit: Name of Authorized Agent for this project:
Ray T(II) nnA s
ner's Mailing Address:
q 0 1 H r"01 c%yj L a k e J9,r
S+okf-,SG7a%e /I C 27367
Agent's Mailing Address:
me Number(33G) 36,9 190 8$ Phone Number
:rtify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Permits necessary to install or construct the following (activity):
.T-+1s�n II n yew 0)& rk
my property located at 3 7 � 1 Ai 5+ S F 84 i a,y (n IV C Ll 2s
s certification is valid thru (date) 7 - 1 S ` J
H J42�--�
Pro erty Owner Signature
(c'.)5-1&
Date

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
— iorn.. N —rYLo m Q 5
Name of Property Owner:
Address of Property:
Agent's Name #:
Agent's phone #:
(Lot or Street #, Street or Road, City & County)
Mailing Address:
I 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 are prop ing. A description or drawing, with dimensions, must be provided with this letter.
7I 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. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. 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, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15' from my area of ripai ian access unless waived by me. (If you
sh 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.
Print or Type Name
Mailing Address
(Adjacent Property Owner Information)
Signature]
Print or Type Name
y 01 1-1 Lela e-% l a k-e Or
Mailing Address

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �. �� n� aS Is
(Name of Property Owner)
property located at 3 7(n 1 A 54. .5 E 6.0 1 , ✓!a n/ C ;x g yd.-2
(Address, Lot, Bloc Road, etc.)
on c.kwcco0 bIl 1aCc in of►-v' N.C.
(Waterbo y) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above loca
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 drawin,
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set b,
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to v
the setback, u 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) (Adjacent Property Owner Information)
Signatu e
Ie 04 U ff rig �•. A S
Print or Type N/yam�e
fi 1 H i o%f'er take d r
Sig�natur
,t c/
Print or Dike Name