69069D - Jeffries

CAMA / ❑ DREDGE & FILL
41ENERAL PERMIT Previous permit #
Itlew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
•ized by the State of North Carolina, Department of Environment and Natural Resources
:oastal Resources Commission ' an area of environmental concern pursuant to 15A NCAC rT
❑ Rules ched.
t Name 1 '� 5 ��f E Project Location: County/i'' �-
r
1 � I
State/ ZIP zc�` f
i0 ) ZGZ yj` �E-Mail
:ed Agent Q �"�
ElCW YEW �.(�PTA S �PTS
❑ OEA ❑ HHF ' ❑ IH ❑ USA ❑ N/A
❑ PWS:
yes P Rol PNA yes�i
Street Address/ State Road/ Lot #(s)
Subdivision
City
Phone # ( ) River Basin
Adj. Wtr. Body "1�� � J-0
Closest Maj. Wtr. Bodyr'�'
f Project/ Activity
(Scale:
i
)ck) length_
latform(s) _
Platform(s)
mgth
ember
id/ Riprap length
Fg distance offshore
iax distance offshore
:hannel
ibic yards
.MP / cy
usek,&atli
c�
not sure yes
)rium: n/a yes no
yes o
Attached: yes no _
ding permit may be required by:
❑ See note on back regarding River Basin

4/21 /2017
11 \ Qllml
Lighthouse Marine
Construction/Darryl
Erny
11VluGlI I iqumUer I amount I
Coastal
Jiles Jeffries Bank Trust 1442 $200.00 GP 69069D

NC DIVISIon 9'€ U0M5't6dj'.1Wttj Ls AArA1l0p�ua
Applicant: )
Dater 1
Describe bel w the HABITAT 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
for.
FIN.
(Ant
(Applied for.
(Anticipated final
(Applied
Disturbance
dish
DISTURB TYPE
Disturbance.total
inciades any
disturbance.
Excludes any
total includes .
1=xcl
Habitat Name
Choose One
anticipated
restoration
any anticipated
or
resf(
teml
restoration or
tern im • acts
and/or temp
Im act amount
restoration
temp i. ti acts
amp
Other
1,A
l"
W
Dredge ❑ Fill ❑ Both ❑
Dredge ❑ Fill ❑ Both. ❑ Other ❑
Dredge ❑ Fill [j.: Both .❑ Other n
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑. Both ❑ Other ❑
Dredge. ❑. Fill ❑ : Both ❑ Other ❑
Dredge 171 Fill Q Both ❑ Other11-
a<;:

—1
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
hereby certify that I own property adjacent to \ `e S `-1 e C 6�40— Lo- s
(Name of Property Owner)
property located at c% 57 A-- A '9t%i /14 e-x,-
(Address, Lot, Bloc , Road, etc.)
on �b/ t� r r 5��� r eQ in -c1 l N.C.
(Waterbody) (City/Town and/orCounty)
The appli ant has described to me, as shown below, the development proposed at the above
locatio
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
�O
WAI ER IECTION
understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be s t back a minimum distance of 15' from my area of riparian access unless waived by
me. (If y 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.
tion (Ad'a nt Pr a Owner Information)
not
wd 1-2i/7 Cl
Noe ka e Print or Tvo Nara

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
property located at
on
(Waterbody)
� 7(__(C- _S ,s
Nam of Property Owner)
4tJT443�
(Address, Lot, Block, Road, etc.)
in , N.C.
(City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
to atio
, & I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELurmtn i
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groi
must be set back a minimum distance of 15' from my area of riparian access unless waived t
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.
(Pro a Owner Information) (Ad'acent Pr ope Owner Information)
ture
. , �T T Print nr Tuna N;;mp