66539D - Thomas

CAMA / El -DREDGE & FILL
qlyd(
"'`4 � 1
iENERAL PERMIT
Previous permit # %�'�— B
New ❑Modification ❑Complete Reissue
El Partial Reissue Date previous permit issued 1.1" -
zed by the State of North Carolina, Department of Environment and Natural Resources
:)astal Resources Commission in an area of environmental
concern pursuant to I SA NCAC t!l 7
/Y �J
Name �� T-1- � �+ IP" A S
E!lRules attached.
Project Location: County sty t114�r
Street Address/ State Road/ Lot #(s
State�J ZIP ? I/ % ', S' / c�:�
t /'+
�$*/'/ E-Mail
Subdivision
dAgent /n7
City I V/;�a-rrliH%��C: ZIP
❑ Cw Wf;E/ A El ES ElPTS
Phone # ( %4') z 7� a -r'1Y River Basin
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
Adj. Wtr. Body
❑ PWS:
es '/ no PNA yes no
Closest Maj. Wtr. Body
Project/ Activity
r
c) length
rm(s)
latform s)� Y
gth
fiber
' Riprap length
distance offshore
distance offsho
nnel
c yards
%%�
�s
(Scale:
g permit may be required by:.
ocal Planning Jurisdiction t *
❑ See note on back regarding River Basin ru
! .

NC Division of Coastal Wgt, Habitat impact computer SWOt
Applicant: Permit Je�� ' S
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.
..F
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
tem � im acts)
FI
(Anti
dis
Exc
re
an
im
0 vV
Dredge Q
Fill ❑
Both ❑
Other
Dredge ❑
Fill ❑
Both ❑
Other [Q
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge Q
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill Q
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Dredge Q.
Dredge ❑
Dredge ❑
Dredge ❑
Dredge ❑
Fill ❑
Fill ❑
Fill ❑
Fill ❑
Fill ❑
Fill ❑
Both ❑
Both ❑
Both ❑
Both ❑
Both Q
Both 0
Other ❑
Other ❑
Other ❑
Other ❑
Other ❑
Other ❑
1Sq. Ft.
TOTAL Feet
for.
I-IMILL I.final
(Anticipated
ipated final
(Applied
urbance.
Disturbance
total includes
disturbanm
Excludes any
odes any
toration
any anticipated
restoration and/or
_
/ortemp
restoration or
temp imped
�t amount) _
_ tempimpacts
amount

AW n► �
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
McCrory Braxton C. Davis John E. Skvarla,
vernor Director Secretary
AGENT AUTHORIZATION FORM
Date: 3 '
e of Property Owner Applying for Permit: Name of Authorized Agent r this project:
(�J e- a
ar's Mailing Address:
Agent's Mailing Address: /
63/ `7 (�//',cA, lCr t�E
/0.0 ;2IfC,/0 3
Email:
Phone ( 9/ 0) ;2 3 I — K S / V
:ify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
ind obtainingAll CAMA Permits necessary to install or construct the following (activity):
rq
ny property located at
�J�s2 13Q Id z 4,
certification is valid 1 year from (date)

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at S S / ,2- LAC, 1,0-
S
(Name of Property Owner)
(Address, Lot, glock, Road, etc.)
on % C C ) in N.C.
(Waaerbody) (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.
(Individual
■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mallplece,
or on the front If space permits.
Article Addressed to:
CJ
$ignature
❑ Agent
✓� 11"
by (Pri ed,_IV�me) I C. Date of Delivery
i2i
D. Is delivery address different front item 1? ❑ Yes
If YES, enter delivery address below: -F No
III I HIM III 111111111113. Service Type 0 ressO
❑ Adult S'gn Restricted Delivery 0 Registered Priorid MMail aiilRestricted
9590 9402 1589 5362 5148 96 CerMW Mail® Delivery
❑ Cerdfled Mall Restricted Delivery ❑Return Receipt for
❑ Collect on Delivery Merchandise
9 Art{cIe Numhar (Transfer from service laben ❑ Collect on Delivery Restricted Delivery D Signature ConfirmationT
di C Signature Confirmation
7 015 0920 0001 9742 9048 dl Restricted Delivery Restricted Delivery
I understand that -/
minimum distane PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Return Receipt '!E
the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property owper InforMaf on)
Print or Type Nafne /
S.�`- wrU e / �yf) -riJ
ld -
Pr' t or Type N II __

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,1I APR' 14 201