66625D - Grady

JGAMA / ElVO(6(DREDGE & FILL NIT fif2
'3ENERAL PERMIT(
New ❑Modification ❑Complete Reissue ❑Partia Reissue
-ized by the State of North Carolina, Department of Environment and Natural Resources
;oastal Resources
Commission in an area of environmental concern pursuant to I SA NCAC
t Name v 1 Project Location:
I fl0 Street Address/ S
It State N C� ZIP
E-Mail Subdivisi
<;
on
_
ed Agent �'� City
St
A B
Previous permit #
Date previous permit issued
01 K
❑ Rules attached.
<! County
ad/ Lox #(s)
1 I1161rt , )[ . I I
ZIP
❑ CW NEW XPTA ES ❑ PTS Phone # River Basin N V&W
❑OEA ❑HHF ❑IH ❑UM ❑WA
❑ PwS. Adj. Wtr. Body 1 vtiW nai
yes no PNA yes / Q
Closest Maj. Win Body
Project/ Activity
i
:k) length
itform(s)
Platform(s) 1�
ier(s) X %Q
ngth
-n\ber
J Riprap length
distance offshore
x dis*ce offshore
cannel
iic yards
se/ Boatlift
Length I'--_
not sure yes
um: n/a yes
yes
ktached: yes
(Scale: 1 "A
ig permit may be required by: �V' iDr« � ❑ See note6n back regar 1 -91tiver Basin
-ocal Planning jurisdiction)

NC DIVIS10111 Ct ®l S A'aI'./�11�6EECiR:7p 4Gp'. foasaRvw«+•— - ,.
Acant:
te: 2� ��-
scribe below the HABITAT disturbances for the application.
ent found in your Habitat code sheet. .
values should
match the name,.and units of measurem
.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
TOTAL SO : Ff,
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE
Disturbance total
disturbance.
Excludes any
Disturbance
total includes .
disturbance.
Excludes any
bitat Name
Choose One
includes any
anticipated
restoration
any anticipated
or
restoration and/o
temp impac4 "
restoration or
temp im • acts
and/or temp
Im act amount
restoration
ternirti acts
amount
/
Dredge ❑
Fill ❑
Both ❑
Other
Dredge ElElFill
Both. ❑
her ❑
Dredge ❑
Fill ❑
Both .❑
Other ❑
Dredge ❑
Fill [(
Both ❑
Other C1
Dredge ❑
Fill ❑.
Both ❑
Other ❑
Dredge ❑.
Fill ❑ :
Both ❑
Other. ❑
Dredge ❑
Fill ❑
Both ❑-
Other ❑

Hurricane Matthew waived

-= ADJACENT RIPARIAN PROPERTY OWN__ `ER STATEMENT
I hereby certify that I own property adjacent to _�V 16 C=r U 's
��S \N � 1 � t_^rY� C 1YICpe of Property ner)
property located at V V 1 UiC Q _
( `u
(Address, Lot, Block, Roo , etc.)
on xA a in L N.C.
(Waterbody) I (City/Town andf6r County)
The a licant has described to me, as shown below, the development proposed at the above
I
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must till In description below or attach a sHe drawing)
WAIVER SECTION
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
Prin�ter Type Ndame
_f La !r/.//Mr��_ _► Lirr,�
Mafflnp Address
.0�00% 0&
clwwaop
O1S - sue- eaa
I___LI - ---
(Adjace/f ProparW Ow er Information)
Signatu
� • .Sr���s
Print or jYp� Name
Mailing A dre r
City/5tat ,p . . ��� D
. . (� .

ADJACEN T RIPARIAN PROPER-1 Y OWNER STATFJWE d"i
I hereby cer* hat I cAn property adjacent to 1 U i Gti C--1 r GtC`M 's
t,�, G } `apse of Property {fin
property etii.ateQ ai i_�%Qc� 1 t� C_� -Ifs _
(Addraws, of Mock, Road m
(Plate bod 1'on in
Zi ,.C.
`�, (Ci'E'1i(; ©! ,7] a:-,cil Dos�nf<y)
The applicant has described to me, as sha n below, he development proposed at the above
Ic�frcn
I have no objection to his propcsal.
l have objections to his proposal.
1� DESCRI.FMON ANDIOR DRA.4NI;XG OF PROPOSED DEVELOPMENT
(individual crop sing devela,.nar,f rnust fill iu descrIp or.• below or ate-; a sate
I; .:.ii/E.R SEC i ION
: understand flat a pier, dock, mc*nng pigs, boat rmnp, breakt.vater, boahouse, lift, or groin
must br z�ef bark a mics4yuyn distance of 15` from .-y area of riparian ass unless %aKred by
me. (tt;-Cu Wish io waive thr setback, you crust ir:itial the appropriate blank belvv-)
I do tAr S : to %-a&e he 1 ssff iack requirement
!,_ not wish to waive e 15' setback requirement.
(Properi� Oiwner Inform2.00p) kdja::enE P1-0
ar Information)
00,07 OP.
SFgnairve Si �'�
Print Type Mama Print cr Type ,Elaine
D2 �.Y.L *-.
MaH- Address ,fig Art ss
�Yd;K e dAf sttrt�
{ T��! 5.�'
i3tlZtp
arcs - sue- a '� :e;ecfrarf2 h+car:�Jentail ad'diess
Tudwnhsnn fs—i..��n ��--

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: D01 1Ctr1
Mailing Address: 9 0 1 �y 1 WD-f 0Y— C 1(df
Phone Number: C 110- 599 • oasg
Email Address:
1 certify that I have authorized ,
Agent I Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at ( f L1 }Llt� t b& OK 0. f eCj P .
in U f) County.
l furthermore certify that 1 am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signatu
Print or Type Name
Tide
: V I ad/7
Date

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