69170D - Davis

CAMA / DREDGE & FILL P� �?, ,l1 q g
Previous permit
iENERAL PERMIT
New -Modification [-]Complete Reissue ❑Partial Reissue Date previous permit issued_
ized by the State of North Carolina, Department of Environment and Natural Resources oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC 07N ' ul a 0 a
Rules attached.
Name .J YV� �� S Project Location: County C� Am
i y Street rAd`drerss// State R�ad/ Lot,#(s)
vt
tatem ZIP_ ��K
(� ll�r�u.r q l'E-Mail Subdivision
ed Agent LGt i'i� �N S u C IGw �t /�Gi�� "( Ci �ti1rl �{(..j Y r;'t" ZIP � K
❑ CW )RTA ❑ ES ❑ PTS Phone ( 0Q) ` t� g &Jver Basin _1AA6&1
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A Adj. Wtr. Body __�(/� � (nat h
❑ PWS: W .
Closest Maj. Wtr. Body
yes / ro PNA yes /
f Project/ Activity \ CA1� �' l-1 , Iz r
6; A �^A (Scale:
ck) length X
atform(s) t
Platform(s)
angth
amber
id/ Riprap length
g distance offshore
ax distance offshore
hannel
ibic yards
mp
use/ Boatlift
Bulldozing r�
"I
1
!ne Length J d
not sure yes
:)rium: n/a yes o
yes
r Attached: yes
j/) (,P <�(� +' 1 ❑ See note on back regarding River Basin
( 1
ding permit may be required by:

NC Division of Coastal Mgt. Habitat Impact COMI
Applicant: _1NV- �M� 0 0
Date: fj rj �(-j
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.
FINAL Sq. Ft.
TOTAL Feet
Fit
(Applied for.
(Anticipated final
(Applied for.
(Ar
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disi
Habitat Name
Choose One
includes any
Excludes any
total includes
Ex(
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
ten
temp impacts)
im act amount)
temp impacts
am
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 0

North Carolina Department of Environment and Natural Resources
Division of CoasW Management
Beverly Eaves Perdue James H. Gregsw
Governor per
J"U
AGENT AUTHORIZATION FORM
Date: 41- I a -- J -2
Name of Property Owner Applying for Permit: Name
//of Authorized tAgent for this project:
Owner's Mailing Address:
Phone Number (V,9 ) �a6- q % l 5
Agent's Mailing Address:
l Cl U _,A2
z-
Phone Number 41 Z13 `7z FAY"
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 necessary to install or construct the following (activity):
a
(my property located) at
This certification is valid thru (date)
Property Owner Signature D e

RECEIVED 05/09/2017 10:21AM
May 820�11 ^.

ADJACENT RIPARIAN PROPERTY OWNER STAAMEN.T Is
(FORA PX14,R4:fOOR WG PHJNGSBOA nIPrIBOATHOUSE)
I hereby certify that I own property adjacent m �ct t/� 5 - `s
(Name of Property Owner) _ _
property located at foa:` ft
k - -'- -- P
�(Lot, Block, Road, etc.)
on Cq/yQ,/ •" �_ Cam' �/r . ire Q��►aK1 �� 1.��4 N.C.
(Waterbody) (Town send/or County)
Applicant's phatte #: Mailing Addreas:JqQ7. ,; I— - tJ)i
He has described to me, as shown below, the deveiopmemt he is proposing at that location, and, i
have no objections to his proposal. I understand that a pierhnooring pilings / boadift l boathouse
must be act back a minimum distance of fifRcen feet (I51 from my area of riparian access unless
waived'by me. (If you wish to waive the setback, you must initial the appropriate blank
below.)
Z e not ravish to waive.
Z dQ wish to waive that setback requirement.
D ,SCRpMON AND/OIt DRAW*C; Ok' VR61?6SED ]t t Vk.OPMANT:
(To be filled in by indlvtduul proposing development)
I'ddk
r
(Information for Property 01VV uer Applying (Riparian Prop" Owner Information)
for permit)
Signature
Mailing Address
City/Statelzip Print or Type Name