66557D - Young

CAMA /❑.DREDGE & FILL A
B
"ENERAL PERMIT Previous permit #
ew ❑Modification [I Complete Reissue ❑Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources —7 `C 1 O
oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC Rules attached.
Name De br \� LProject Location: County NV\SVvI
Street Address/ State Road/ Loft #(s)
State ZIP
SubdivisionE-Mail
ZIP ���
ed Agent L Asti 1` V'i S City
❑ CW *TA AS [XPTS Phone # () River Basin
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body _CO-. V\ �"k (nat h
❑ PWS: )NJ V / "
-�--� -�, Closest Maj. Wtr. Body
yes / lfi', / PNA yes / 6o, f
' Project/ Activity
G�.
ck) lengf11 �
atfor (s)
PPorm(s)
rfer(s)
�ngth
amber
i4 Riprap length 67
g distance offshore
ax distance offsF ore
hannel
H12"EM
i
not sure yes o
xium: n/a yes o �v UV iiC
yes no V
r Attached: yes no
ding permit may be required by: �CJ� Q �V �f
� `
o I nrni Pinnnino lurisdiction) I I 1 t I
a
(Scale:
❑ See note on back regarding River Basin

NC Division of Coastal Mgt. Habitat Impact Coml
Applicant: IJ�IJ�` `IbUVk
Date: v C !�
Describe below t e ABI AT 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
FIB
(Applied for.
(Anticipated final
(Applied for.
(An
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disl
Habitat Name
Choose One
includes any
Excludes any
total includes
Ex(
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
terr
tempimpacts)
impact amount
tempimpacts)
am
� II
D W
Dredge ❑ Fill K Both ❑ Other ❑
1 0 0
100
Dredge ❑ Fill Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue .farm H. Gmgw Dee Free
Governor Director
AGENT AUTHORIZATION FORM
Date: to to
Name of Property Owner Applying for Permit:
Owner's Mailing Address:
2?Gib
Phone Number
Name of Authoriiz//ed Agent for this project:
Agent's Mailing Address.
Phone Number U 14'). `1113 -
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necTary to install or construct the following
(my property located) at
This certification is valid thru (date)
0
Ell
Prope y owne�ture � o Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that own property adiacert to ! 0-�: ✓� s
(Name of Proptirty Owner)
property located at
(Address. Lot, Block, Road, etc.)
onyy t.
(Waterbody) (CityrTown and/or County)
Tne applicant nas descnbea tc )e as s"own below the oevelopment proposed at the above
to Eon
/Y Y� iFave no objection to tnis proposal
I have objections to this prcposa
lk
DESCRIPTION ANDIOR 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 'amp 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 ,egwremerlt
(Property Owner Information)
Print or 7 ype Na-c
(Adlacent Property Owner Information)
1 ! Jznul !/1't' r
IVarn�—
f

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ,v►- 4 Y/i6ra-ce C s
(Name o Prop Owner)
property located at /
(Address, Lot, Block, Road, c.)
on Liin SIN s• k gie'a" 4 , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc iqn�
x 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.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
'2—
'-Kignature ) /
Print or Type Name
/ qA 7 K ,;, I,,-
(Adj Propeply Owner Information)
Signature
Print or Type Name