67128D - Waterson

CiCAMA / ❑ DREDGE & FILL A B
�/
GENERAL PERMIT Previous permit#
kNew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued`
orized by the State of North Carolina, Department of Environment and Natural Resources � 1
Coastal Resources Commission iUV
n an ar a of environmental concern pursuant to 15A NCAC U r
❑ Rujos attached.
.nt Name y '�'� l U Project Location: County -A
s Street Address/ State Road/ of #(s) • ' `j StatwAi ZIP '� 6t; �. /,p.
Subdivision
ized Agent ► I ItA City i ,TOOaAX ZIP
d ❑ cW >EW PTA ❑ ES ❑ PT� S Phone # ( ) — River Basin
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ WA < nt
Adj. Wtr. Body
❑ PWS:
yes no PN y�no
Closest Maj. Wtr. Body ✓�" `'�..`
A Project/ Activity
(Scale:
lock) length . / � -0 1/
Platform(s)
ig Platform(s)
Lvg i
nax
:ubic
Boatlift
line Length (4y
notsure yes
orium: n/a yes
s: yes
r Attached: yes
ding permit may be required by: !� el% ��'V! ❑ See note on back regarding River Basin
e Local Planning lurisdictionl

NC Division of Coastal .Mgt. Habitat impact. Computer Sheet
Applicant: (� /
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.
TOTAL Sq. Ft.
for.
FINAL Sq. Ft.
(Anticipated final
TOTAL Feet
(Applied for.
Fit
(Ar
DISTURB TYPE
(Applied
Disturbancetotal
includes any
disturbance.
Excludes any
Disturbance
total includes _
dis
xi
res
Habitat Name
Choose One
anticipated
restoration
any anticipated
or
res
ten
restoration or
ternimpacts)
and/or temp
act amount
restoration
tem im acts)
arr
Dredge ❑
Fill ❑
Both ❑
Other
Dredge El
Fill ❑
Both ❑
Ot er ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge. ❑.
Fill ❑
Both ❑
Other ❑
Dredge 0
Fil1171
Both ❑
Other E❑

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
DateJ' `•
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent)
to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
i
install or construct (activity) I, ..
at (my property located at)
D� l 1 (
This certification is valid thru (date)
C-�7,sq4 C-)
Signature
IS9
Date

UIl,as
`33�i �,stE
CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONlWAIVER FORM
Name of Property Owner: v V� vv ~ !
Address of Property. �� —�-- ' `-'-�' ` (Lot or Street #, Street or Road, City & County) Ci Q nG�C
Applicant phone #:943 J-Losg 6 I_L— Mailing Address: 1 L l j' > �`�
I hereby certify that I own property adjacent to the above referenced property. Tt! individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing with dimensions, must be provided with this letter.
DC', 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. Contact information for DCM offices is
available at www.nccoastalmangement.net/contact dcm.htm or by calling 1-888-4RCOAST. 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, or lift 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 Informgtiorn -I
SIg1I
Print or Typel Name
`7
Signature ;
Print or Type Name
AA.W— Arlrlrvcc

&ff,45 = 3f/f/'/ 'J� Pf Y-'A- D
b
CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or Street #, Street or Road, City &
Applicant phone #:`I `t-Mailing Address:
_J r
1
I hereby certify that I own property adjacent to the above referenced property. Tkrd individual
applying for this permit has described to me as shown on the attached drawing the crt��Ielopment
they are proposing. A description or drawing- with-ctimensions must be provided- iF��y►.---
I 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 Coasta;.Vanagement
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at www.nccoastalmangement.net/contact dcm.htm or by calling 1-888-4RCOAST. 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, or lift 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
SignahyEeJ
P�rT Name
Mailinn A dress
(Riparian Property (),#ner Information)
Signature.
Print or Type Name
X ((: i.3 7
Mailing Address

T