67256D - Yamouti

`LAMA / ❑ DREDGE & FILL A B
;ENERAL PERMIT Previous permit#
l Jew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
•ized by the State of North Carolina, Department of Environment and Natural Resources 7' j
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC n ! N - �� �✓
p i ❑ Rules attached.
t Name 1 V1 L r-Oiy �I ✓�VMOU�i Project Location: County &VASVV 1 ( 1 •
tK ' p,vt'I--btn State km( ZIP 4-9 Q 5J S
E-Mail
edAgent
❑ CW )<EW
APTA ❑ ES ❑ PTS
❑ OEA ❑ HHF
❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes / no . PNA
yes /
' Project/ Activityt
tt
::a
Street Address/ State Road/ Lot #(s)
.d
Subdivision
City ��,� V\n ZIP
Phone # River Basin j,t/yl/\
Adj. Wtr. Body !" nat i
Closest Maj. Wtr. Body wy )
i ,,L r c� b `V`t Q., i �t `�5� eU� i% i X'_' - C� S� (Scale: „
_, ..--- -_i-
Local Planning Jurisdiction) ,pry 9

NC Division Of Coastal Mgt. Habitat impact Computer fibeet
Applicant ` t�UJ Permit #:
Date: + U/
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.
(Ap'p..lied..for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
andfor temp
impact amount
TOTAL Feet FINAL Feet
(Applied for.. (Anticipatedfinal
Disturbance disturbance.
total includes Excludes any
any anticipated restoration and/or
restoration or temp impact
temp impacts.) amount
r A
oV�.J
Dredge [IFill ❑ 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 171
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 0 Fill ❑ Both .❑ Other ❑

FA
.A
k.1W
HCD
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
)rly Eaves Perdue Braxton C. Davis
ernor Director
AGENT AUTHORIZATION FQRM
Date: f 9 ' 14
of Property Owner Applying for Permit:
c., or N • YA0100b
)es MefNng Address:
I ZiUefS4V_ �T
' 6S
e Number 02z$1 H 3 9' 3 6b 3
Dee Freeman
Secretary
Name of Authorized Agent for this project:
Agent's Malling Address:
H5 _ 2798 Sea Vista Dr.
_ CONS78OCTION Supply, NC 28462
Phone Number Aot SYD ` i 3g i
ly that I have authorized the agent listed above to act on my behalf, for the purpose of applying
►d obtaining all LAMA Permits necessary to instal or construct the following (activity):
ny property located at , ! 3 Z n�• S�/cc-�- �, 0. !�.
;ertification Is valid thru (date)
Property O er Signature Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to V i c�u r Y� ✓►'� ° ��''s
a STICK �' Name 8f P perty Owner)
property located at �� 3 E. Z r 3 ��ss
(Address, Lot, Block, Road, etc.)
on t 6. Y\ t,1 , in 6ro n 5 N', c- V 0 N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc n-
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(fndividdal proposing development must fill in descilption 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.
I do not wish to waive the 15' setback requirement.
n
(Property Owner Information)
L,-,n �-"
S* tureJrz
Uitve dV
P ' t or Type Na
G 1-% <^V-rlms dc Oi
Mailing Address c
Maj/ F-PY"F" „ i(-
winformation)
. Q�/'�v Z31e PUl4
L L C_.

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to V t C:�u r y6 V-Y `0 0-'` I
property located at- (Name Qf property Owner)
(Address, Lot, Block, Road, etc.)
on Y) C" in ('�{ o n s " c. N.C.
(Waterbody) (City/Town and/or County)
The applican 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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(tn*4dual proposing development must fill hi "it cfiption 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,
I do not wish to waive the 15' setback requirement.
111 (Property Owner Information) (Adjacent Property Owner Information)
Si ature Si ture
Pri t or Type Name Pript or Type Name
AAc X-- A,4,4- AAAdinrr Aridrp CS ..