68077D - Lysaght

_iCAMA / El DREDGE & FILL Qt�► 3,�j ,�`, $® � A B
GENERAL PERMIT Previous Permit#
[slew -Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
irized by the State of North Carolina, Department of Environment and Natural Resources -7 ; ( �t7 �/�
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC 6 1 �T {• V
ll t (� ❑ Rules a hed.
a nt Name M �+ fly- Vn d 0 VI h-C i�� ti Project Location: County {-� (WSV"%-(
WCA 1 T/V% iU�} vv1 Street Address/ State Roaad/_Llot #(s)
OV11 State ZIP_'A
'EnMail °►ln t, i �ubd'ivision
zed Agent r �ci� j `o_c. , Al i� M�1,.�1-t �Ci 1M �C(C ZIP -VA
d ElCW f'PTA ❑ ES ElPTS one # (��� ) Z� River Basin)
ElOEA tF b 1H ❑ UBA ❑ N/A Adj. Wtr. Body aV�t CVYt. K (at ate
❑ PWS: 1
yes / 061 PNA yes / no Closest Maj. Wtr. Body— _A1 W\L
>, Project/ Activi>_,� h
ock) length
'latform(s)
g Platform(s)
pier(s)
length
umber
;ad/ Riprap length
vg distance offshore
lax distan%� offshore
channel /ET
0
(Scale: I 4%
ng permit may be required by: _
Local Planning jurisdiction) n
❑ See note on back regarding River Basin

-NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: �(/�ti VZ& �o��,.�. ���- Permit #:
Date: ev
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
ternimpacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Other
�Q
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fili ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both [❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other 0
Dredge ❑ RI ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge [i Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

Completeitems 1, 2, and 3.
Print your name and address on the reverse
so that we can return the card to you.
Attach this card to the back of the mailpiece,
or on the front if space permits.
Article Addressed to:
,�►,�u � off �
) a-)
l III' I'll Illl IIIIIIIIIIII Il IIIIIIIII
9590 9403 0319 5155 0688 77
Ariirla Ni imhPr (Transfer from service label)
7015 3010 0000 7848 8631
corm 3811, April 2015 PSN 7530-02-000-9053
■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
�ylT�,�
A. Signaturb,
-KAgent
X ''' ❑ Addressee
B. Fl6ceived by (Printed Name) C. Date of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Service Type
❑ Priority Mail Expresso
❑ Adult Signature
❑ Registered MailT1
❑ Adult Signature Restricted Delivery
❑ Registered Mail Restricted
Otertified Mail®
Delivery
❑ Certified Mai Restricted Delivery
❑ Return Receipt for
❑ Collect on Delivery
Merchandise
O Collect on Delivery Restricted Delivery
ElSignature ConfirmationT"
n 1—ird Mail
❑ Signature Confirmation
•ed Mail Restricted Delivery
Restricted Delivery
$500)
Domestic Return Receipt
nature
❑ Agent
�- ❑ Addressee
ived by (Print d ame) C. Date f Delivery
I�iG L L�j 7
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: 12190
%
IIIIIIIII I'll (IIII III IIIIiI ii IIII IIIIIII
III III
3. Service Type
0 Adult Signature
❑ Priority Mail Expresso
El Registered Mail-
0 Adult Signature Restricted Delivery
fied CertMail®
❑ Registered Mail Restricted
9590 9403 0319 5155 0688 53
11
❑ Certified Mail Restricted Delivery
Delivery
O Return Receipt for
?. Article Number (Transfer from service label
❑ Collect on Delivery Merchandise
❑ Collect on Delivery Restricted Delivery ❑ Signature Confirmation -
7 015 3 010 0000 7848 8655
I Mail
1 Mail Restricted Delivery
❑ Signature Confirmation
Restricted Delivery
500)
'S Form 3811, April 2015 PSN 7530-02-000-9053
Domestic Return Receipt
rn4y-,
CD
0
O
C
v,
w
00

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Xrk i I-YSa
Mailing Address: %Sacj 11Vrfr ,�
l�U�,on U H
Phone Number: , .L
Email Address: �nl nnitvi., ��/SGa�I t�' Q�?�*Co&1
� v
I certify that I have authorized x �%r� �r�rn r; LLL
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: '0'/ii '
at my property located at q66 Z%rh. Sl�n, 4fA ,
in i8tor5wfc/L County.
1 furthermore certify that I 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:
Signature
L
Print or Type NaMe
O vVVLr
Title

I

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
y !) -
Address of Property: �
(Lot or Street #, Street or Road, City & County)
Agent's Name #:
Agent's phone #: tha-,t 3,)' 3L)
LIV
Mailing Address:
hereby certify that I own property adjacent to the above referenced property. The in ivi u,
applying for this permit has described to me as shown on the attached drawing the developmei
they are proposing, A description or drawing, with dimensions, must be provided with this letter
I 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 Managemei
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices
available atlittp://www.nccoastaimanagement.tietlwcblcmlstaff-listin orby calling 1-888-4RCOAS
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, boat ramp, breakwater, boathouse, or lift must
be set back a minimum distance of 15' from my area of riparian access unless waived by me. (I
you wish to waive the setback, you must initial the appropriate blank below.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Info mation)
Signature
(Riparian Prop" Owner Information)
Sigl atuN