68007D - Farrior

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: Permit #:
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.
Habitat 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/or
temp impact
amount)
Dredge ❑ RIX Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other
lei
1
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 ❑ Other ❑

Payment Proccessing Confirmation
Date Received 2/2/20171
Check From (Name) Allied Marine Contractors Inc
Name of Permit Holder Stanley Farrior
Vendor First Citizen Bank
Check Number 5286
Check amount $1,400.00
Multiple Permits Yes
Major/Minor
Permit Number/Comments GP 68007D, Permit Fee $400
Receipt or Refund/Reallocated TM2805D

LA.
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date / ]�� tl , � -- 2 /
Name of Property Owner Applying for Permit:
Mailing Address:
To , SOx
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
install or construct (activity) 6y/Iz- k
at (my property located at) `Z 7 0 R ZIC
This certification is valid thru (date) 12 - 3 t - 1 -7

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOA TLIFTIBOA THO USE)
I hereby certify that I own property adjacent to ` )inn IC&rrt -or 's
l f�, (Name of Property Owner)
property located at l 02 7 `✓o K # ye, '
(Lot, Block, Road, etc.)
on c�%1 C , in / fli�5ce�' ( �fC� �t , N.0
(Waterbody) (town and/or County)
Applicant's phone #: &, Mailing Address: T Z `/z�y �� C
He has described to me, as shown below, the development he is proposing at that location, and,
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathous(
must be set back a minimum distance of fifteen feet (15') from my area of riparian access unlesE
waived by me. (If you wish to waive the setback, you must initial the appropriate blank
below.)
I do not wish to waive N/04
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
Csee cff���>
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
/2
Mailing Address Signatu

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTB/O�ATHOUSE)
I hereby certify that I own property adjacent to �j /, frt b r is
(Name of Property Owner)
property located at 7 6D , V ',,' /� V, e. '
(Lot, Block, Road, etc.)
on agev , in ��Sa�t ( -4e G , N.C.
(Waterbody) J own and/or County)
Applicant's phone #: '/�0 3!v ~7 02 /.5 2 Mailing Address:
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive N114
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
Sec
(Information for Property Owner Applying
for Permit)
q2 �1-0 l�
Mailing Address
(Riparian Property Owner Information)
Signature

fl, Piro o` ,�
1
eXr3f1�
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