66628D - Williams

(CAMA / []DREDGE & FILL 1 I„
ENERAL PERMIT
New ❑Modification ❑Complete Reissue ❑Partial Reissue
A B
Previous permit #
Date previous permit issued
•ized 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 (� •'� ll
� . ❑Rules attacFj�d.
t Name �fi` L Dc I Y� � 1 ,�/ t11(1�S Project Location: County V s
jD 6 r1"% Lava, Street Address/ State Road/ Lot #(s) -
? State ZIP V1 $ D 1 j\ b ` Y\ .1 O o O--t. 7�
E-M •1 p W 0 .0 S 3'91 a%�►� (T•('Y§ubdivision �r -
ed Agent ( CCity ��' ZIP�Q
El CW EW A El ES El PTS P one
El# (� )5 �i O " (r s 1y River Basin L LAM
❑ OEA ❑ HHF IH ❑ USA ❑ N/A Adj. Wtr. Body ti 1 nat
ElPws: 1 Y
-- 1 .4�- OMA Closest Maj. Wtr. Body
,- - L t
ing permit maybe required by: IOW\A 0 k1aJcL'\ ��lt
Local Planning Jurisdiction) ,I _ It ,-%
❑ See note on back regarding River Basin r

YC Division of Coastal Mgt. Habitat impact Computer Sheet
applicant: w, ' ' �J� Permit #, w tJz 4
)ate:
w�lwctiUtiti�
)escribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
Dund in your Habitat code sheet.
labitat 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 Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/o
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Other
l
Lo
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 ❑ 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 ❑

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date M a 4,
Name of Property Owner Applying for Permit:
Pair+c�a F.
Mailing Address:
505 C0o� ctae L,&a.t
6QLkfk<rA R'nes. /1C ZS3R7
I certify that I have authorized (agent) _�� r� A ©/ J e n to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) ho a4 I ,' f I f MQ V- 0 o a4 LA a 0 c K ,
at (my property located at) 115" C k m r l o 4 4 e S d r e e d- ld o /den & a c 1. A.G
This certification is valid thru (date) ! — 4 I I
Drnrnr/t� iimnnr L'itrnot�.�n notn

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby, certify that I own property adjacent to M c, h ae I lnl"/I " any 's
11 (Name of Property Owner)
property 16cated at ► a 5 C oLr / o l 1 c. S (r-e e l, /J o l d e r\ Raa- c& N C.
(Address, Lot, Block, Road, etc.)
on canot..� , in Aol den Read , N.C.
(Waterbody) (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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill in description below or attach a site drawing)
� 1a'Ji A d Oc..K ryl.oJe
4-o I e-f � 4-c Jr:,e vP
vv k r.0L-r4`P
�'ns�arl 600,4 i;Cf or
r-19k+-
See �� e �0.� Jr -a"
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)
Signature
N ke I D W / ('c�iY.
(Adjacent Property Owner Information)
Signature
t',� y CAI2 -MA Z.
Print or Type Name
Print or Type Name
n ... i, ter.. e . .. .

■ Complete items 1, 2, and 3. A.
■ 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 mailpiece, B.
or on the front if space permits.
Article Addressed to:
M `�d z _F -1 ,JaI-J F_ 4 -1 S
c o TO otA n, � ct
Ik-
C I;nLan, �I fry.
71" Agent
❑ Addressee
Received by (Prints Name C. Date of elivery
Is delivery address drfferent from its 11 ❑ Yes
If YES, enter delivery address below: ❑ No
II
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I II
I II I IIIII
I II
I I II
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a.erype❑
❑Adult Signature
Priority ed l Express®
❑ Registered lVExpr❑Adult
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Signature Restricted Delivery
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Delivery
2. Article Number (Tiansfe/from Service labell
Certified Mail Restricted Delivery
❑ Collect on Delivery
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❑ Return Receipt for
Merchandise
' —
Delivery
❑ Insured Mail
❑ Signature Confirmation-
7015 3 010 0000 0356
❑ Insured Mail Restricted Delivery
'0i
❑ Signature Confirmation
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o ,
6533
Domestic Return Receipt
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