69078D - Hendrick

f IA
;;LAMA / DREDGE & FILL
'E NERAL PERMIT Previous permit# #A B___
New -Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
rized 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
❑Rules attached.
t Name ftOl, l �/U Project Location: County t C. ��
State K"C—' ZIP
E-mail
ed Agent 2Xy A N T�4 l.a#-- tt oW Z-
❑ CW P�rTA [IES ElPTS
❑ OEA ElHHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes no PNA yes /no
Project/ Activity
is yar
p
;e/ Boatlift
11dozing
Lengdh /_ �Z
not sure yes
0 Qt-A& w4
Street Address/ State Road/ Lot #(s)
'v
Subdivision C'••;i
City WY ZIP
Phone # ( ) 1 River Basin \d
Adj. Wtr. Body_ �u " '0. GLUA4, �
Closest Maj. Wtr. Body N -E�
105 "Wtt'� n

nucu1V GU I LG
4/10/2017
�i�auw� I
Holly Hendrick same
i
BB&T 1204 $200.00 GP 69078D

rr'a�®n ®f Goast�i :t lc�t, Heai�itat Impact- C6
H� �e. p> ter
Applicant: `
Date:
Describe 6elow the HAB TAt 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 FIP
(AppUed for. (Anticipated final (Applied for. (An
Dis
DISTURB TYPE Disturbancetotal disturbance. turbance di c
includes any Excludes any total includes. Exc
Habitat Name Choose one anticipated restoration any anticipated res
restoration or and/or temp restoration or ten
tern im -acts im act arnmount ternl0 acts am
Dredge ❑ Fill ❑ Both ❑ Oth
Dredge ❑ Fill ❑ Both. ❑ Other ❑
Dredge ❑ Fill Cl.-Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑. Fill ❑ . Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other

AGENT AUTF,,'RIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: _4 o t T. H ewLo(�IU
Mailing Address: ►al CRecks Eo�-E. -C>rZXvE
5 P4 F Ftb 5 V-E rz i2y , nl C- 2_ 'k y 6 O
Phone Number: ' f _ 3 569
Email Address: b►U►Iy , In-e- 8r%'c1-'- G &A4AIL. . c.oA
I certify that I have authorized B Q`t A f4 T14\4L O P- CLo M T �--
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development
SNz--Abs TFr--Q-R { , r4e-,
C✓e.a6TT 5 GAFj--Ar- csTA7-;-=5,
at my property located at J-oT Y5 , K:-YEAF�TT )LOpp Zvilxe¢
in UN51-0W County.
1 furthermore certify that 1 am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Ofcer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signature
Rio I ly .l 1-�r.►nd�ri cam.
Print or Type Name
Title

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to H oL_L-y NE ND f2�G►L
property located at L'oT 14 r�
on F-v�RETT s CREEt'L
(Waterbody)
I
(Name of Property Owner)
1=VE%ZETT yp �1�LlVE
(Address, Lot, Block, Road, etc.)
in_ snlE-ftD5 FE-iz2y Z0d5/-04� N.C.
(CitylTown and/or County)
The applicant has described to me, as shown below, the development proposed at the above location.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill in description below or attach a site drawing)
See ok� d Ne c4
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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)
wit snirin.c�,
Signature
ha oLL4 J- NE-NIDRkck.
Pnnt or Type Name
t a% CrcecKs EDCsE
Mailing Address
(Adjacent Property Owner Information)
Signature
Ehflot{t� �J 18a.r ba.Ycc.
Print or Type Name �-
104 'PhAxAt' 13awk I►-
Undinn drlrfmcc

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: H O L L ,T H e N Da % c I{
Address of Property: L-07 *# 45 EVeaETT yvpi pr1kuE. o10S1-oti,
(Lot or Street #, Street or Road, City & County)
Agent's Name #: -e, P-y enl T"L, 69 0- Lo rU T2_
Agent's phone #: 252 21 It gyg�{
Mailing Address: 3208 5. C4u ,,.Ie-s 31 vo
(Tvczn/✓, LLE n/G 2-7 SrSir'
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are 9poposing, A description or drawing with dimensions must be provided with this letter.
_ VI have no objections to this proposal. _ I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no objection if you have been notified by Certified Mail
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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
HaLLy J N�rtna�cK
Print or Type Name
k 3 \ Cfte./= KS E-O (-F_ p #QXVF
(Adjacent Property Owner Information)
A Z qPW -J,_4
Si gnature
-PAT IoPPP TPF-ErvtAn1 -V-t 3o►WArX%-i
Print or Type Name
113oro Nwy 36
Mailing Address
Mailing Address

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