69159D - Heath

AA DREDG
FLL
ERAL PERM IT e ❑Partial Reissue
A B
C
Previous permit #
Date previous permit issued
❑Modification ❑Complete Reissuvironment and n�O
pursuant to 15A NCAC -t ❑Rules at jd� ( r
y the State of North Carolina,
nlian area of environf En mental concern p Natural Resource r
Resources Commission
Project Location: Countyne t
Street Address/ State Road/ Lot #(s)_�t / Ll J
l c°._
zip
NG 2
State j "L l I Si� ay J
Subdivision 7 rh
H� E-Mail Ca 0 ZIP
City �V i j't ti i N�1� —_—
�I ) ) River Basin (�
kgent j Phone # (—)
A ElES ❑ PTS �a G 1 a man
I CW W ❑ USA ❑ N/A Adj. Wtr. Body
I OEA ElHHF ❑ IH
Pws:------- Closest Mai. Wtr. Body
PNA es no
roject/ Activity
length 2 U' 1
orm(s) .10
X �—
atform(s)
rth
Aber
I RipAPIgth_�
distance o hore�
c distance of ore
annel
sic yards ��—
np !
Js oatli
Bulldozin
(Scale: Yf-
❑ See note on back regarding River Basi
-- 0.24-4 OCtIli 1iA 1

Date Date
Received De
4/27/2017
%-neci+ I Holder
(Name)
Bartley Heath same
BB&T
1119 $200.00 GP 69159D

t i p habitat impact GOA putgr Sheet
Division Of coal P erm I.t #:
cant'. ` e
es
and units of measurement
antes for the application. All values should Match the nam
TOTAL Feet FtN, . Fee
finat
cribe.below the HABITAT disturb Ft. �INpL. Sq. Ft. A lied for. (Anticipaf�
nd in Your Habitat code sheet. TOTAL- Sq. Anf�L. S d final (pp disturban0l,
(gpp[ied for. ( 6Uf.bance- Disturbance (dudes any
total includes restorationandfor
Disturbance total dudes anY an anticpated .
DISTURB TYPE includes anY Cowation _ temp impact
anticipated restoration or amount
Choose One and>ortemp temp impacts
bitat dame restoration or
mood
amount
Dredge[] Fill ❑
Both ❑ Other
Both ❑ Other
l
Dredge ❑ Fill ❑
Dredge ❑
Fill ❑ Both ❑ Other ❑
Dredge Q Fill ❑
Both ❑ Other ❑
Dredge ❑
Flit ❑ Both ❑ Other ❑
e Fill ❑ Both ❑ Other ❑
Dredg ❑
Dredge Q Fill
Both ❑ Other ❑
Dredge Q
Flit ❑ Both ❑ Other ❑
Dredge ❑
Fill ❑ Both ❑ Other ❑
` Dredge ❑-
Flit ❑ Both ❑ Other Q
Dredge
Fit'[] Bath ❑ other ❑
❑
Dredge ❑
Fill ❑ Both ❑ Other ❑
Dredge ❑
Fill ❑ Both ❑ Other ❑
Dredge ❑
Flit[] Both ❑ Other ❑
Pk n Other Q

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date � 1 q l � 9
Name of Property parser Applying for Permit:
,Rartfel He-att
Mailing Address:
C O3 `AL
Pn to act on my
a eat �r '
I certify that I have authorized ) permits necessary to
behalf, for the purpose of applying for and obtaining all CAMP►
install or construct (activity) 3� i l
ro located at) Ljj 3f SCA n Z Ora
at (my property
This certification is valid thru (date) :1 3 0� `�
Date
Signature

AOJ C RfPARfAN PROPERTY Otl NF-5
TE FiT
adjacent to of Property Owner)
1 hereby Certify that 1 own groPedy (Nara
Sd, etc.)
property located at (Address, Lot, Btoc//k,7, n N.C.
(CdylTty]
own afndfor Coun
on
(Waterbody) ro sect
The appi�ant has at the above
described to me, as shown below, the development p po
tocati I have no objection to this Proposal-
_ I have objections to this proposal. ELOPMENT
G OF PR
DESCRIPTION
ANDIOnt mustN fill in des option below r attach a site drawing)
(Individual Proposing
X
WAIVER SECTION lift, or groin
t understand ti a pier. dock, mooring pilings, boat ramp, breakwater, boathouse,
must rs set back a minimum distance of 15' from my area of riparian access unless waived by
setback, you must initial the appropriate blank below
me. (If you wish to waive the )
_ I do wish to waive the 15, setback requirement.
I do not wish to waive the 16 setback requirement.
(Adjacent rOwner information)
(Pro Owner information) ,i r
rry� Si t e*
S' r' {1e r t(^ =="`
r+ Print or Type Name
Print or ype Name c 11
n e. G M h g Address Z r l
Mailing Adi
Crty/StarelLp
^' rt� 1 �y ' d �v„ �t E h eK+�, J,,,:., l .c ,„� fez 7 3 1 s 3
Nr,mbe 1 email a Tess Telephone �} mbef ! email address
7 /i7/i7'

7 T
pp�pCEN7 RiPARiAN PROPERTY OVUNE ,s
I hereby certrfy that 1 own property
adjacent to (Nam of Property Owner)
SCE e
props
(Address, Lot, BJOc d+ etc.) N.C.
� located at 2 f
In City/Town ndlor County)
on /r�Cs �� (
(Waterbody) development proposed at the above
Th�*��<haq
ap
nt has described to me, as shown below' the
lthis proposal.
e as �yecttan to
I have objections to this proposal.
tttfiNG OF PROPOSEQ QEvEtOPMENT
QESCR1PTlONAo Q/merR►t t fill in description below or attach a site drawing)
(individual proposing dev P
WAC SECTION lam, or groin
breakwater, boathouse,
moocire9 prl�r�gs, boat ramp, riparian access unless waived by
1 understand that a pier, dock, m ar8a of
waive the setback, you must initial the appropriate blank below.)
must be se�b� � a minimum distance of 15' from
m
e. (if i
t do wish to waive the 15' setback requirement.
1 do not wish to waive the 15 Setback requirement.
&Ain Property Oytner Inforn'ration)
(Property pwner information)
C
c
Print or Type Ne Cf �'fe 8! v
City/StatelZO Z $ c./p /
j •C^ / email address
�eQp�one/3/ N«gy 2,2O~Z�/�