69132D - Heavner

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant:
Date: ocl %a-7/1ci--7
Permit #:
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/o
temp impact
amount)
' r
Dredge ❑ Fill ❑ Both ❑ Other
I
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 [I Both C] Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

Pat McGay
Governor
QUAw
North Carolina Department of Environment and Natural Resources
N.C. Division of Coastal Management
John E.
se
AGENT AUTHORIZATION FORM
Date: 3 �2 h-2
Name of Property Owner Applying for Permit: Name of Authorized Agent for this projec
J _L ne- ot.\•ns
Owner's Mailing Address: Agent's Malting Address:
Email: CC +n l foNl c �i l�'P-r e% ��� az I �, Email: Ate- ks 2 [fie nir-.1
Phone ro �A_- 6 Phone - C VI a
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applyinj
for, and obtaining all CAMA Permits necessary to install or construct the following (activity):
For my property located at
T►;i n rtAi•ftfinn ie v7!v4 1 uanr from (ri=W

v -
(:ERTIFIED ; AIL - R> tRN RECEIPT
REQUESTED
DIVISION OF COASTAL MkNAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner.
f�
Address of Property: _26 6 L7 o r _ /1
(Lot or street #, $erect or mod, City
Applicant's phone #: 71D -k L2 .-e % �, 4
Mailing Address.
I hereby certify that [ own property adjacent to the above rzfcren� —
has described to me as shown ore the attached drawing Property. The individual applying for thi
with dimenct....� must be � �' are development proposmp � d-��--�.�.1�' s+w �14i ell •C t,Mfar tr g"`.• •�i..iV77 of
C
[have no objeC,irons to this proposal.
______ I h"e objections to this proposal.
if YOU have objections to what is be'
ng in writing within 1d der of Pam ' rO° D°Wt notify the Division of Coastal
ys receipt of this notice. C �agement
Wilmington, NC 284�5-3845. �M o�Pondence should be mailed to 127 Cardinal Dri
considered the representatives can also be contacted at 910 796-721& No
same as no ob'ecliorr it n have ( ) respos.
been aoti5.•ri tib r-_...:�_� .-_ ..
I understand that a ier, dock, WAIVER SECTION
15' from m f mooning pilings, breakwater, boathouse, or lift must be set back a minimum
disd
Y area of riparian access unless waived by me. (If you wish to waive the setback, you must initial i
appropriate blank below.)
[ do wish to waive the 15 ' set back requirement.
1 do not wish to waive the 15' set back requirement,
(Property Owner Information)
,
S' lure
�--Qx��
Print or Type Name
90
Mailing Address
city/ State Zip
Telephone Number 1�1 4!� - Y1I--71 Cf¢(91/
Property
Print or Type Name
Information)
�A-V-�At,
Mar dress r
City / State 4 Zip —

(,'lrlt'1'1FiED : A1L — RETiJR,�! RE('F� REOUES'TED
DIVISION OF COASTAL MA.NAGEMENIT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner.
Address of property.
(Lot or Street li, Street or R,. di City
Applicant's phoneiv: 7'l1)- /Z-0 7l, q
Mailing Address:
I hereby certify that 1 own Property adjacent to the above referenced
has described to me as shown on -the attached drawingP"DP The individual applying fa
with dimrrsions m��t ►� Provided with the 1 development they an proposing. Agg ri�
7 I have no objections to this proposal.
_______ I have objections to this prope
If You have objections to what is being proposed, you most notify the Division of Coastal Manag
in writing within 10 days of receipt of this notice. Co emc
Wilmington, NC 2805-3845. DCM representatives ^�Pondence should be mailed to 127 Cardiac
can also be contacted at [phone]. No res
considered the same as no ob ecrion if ou have been nntifim t—
1 understand that a pier, dock, mooringilia WAIVER SECTION
15' from my area of riparian access unless ess ng v�k�«' �o�' or lift must be set back a minimum
appropriate blank below.) �' me. (If you wish to waive the setback, you must W1
do wish to waive the 15' set back requirement.
1 do not wish to waive the 15' set back requirement
(Property Owner Information)
Si ture
Print or Type Name
Mailing Address
City / State I Ztp
Prop" Owner Informati
Mailing Address
try / t tc / ip

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