67982D - Lewis

NC (Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: LP S Permlfi #: %/J ¢ •
Date:
Describe below 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,Fdisturbance.
et
(Applied..for.
(Anticipated final (Applied for.
final
Name
DISTURB TYPE
Choose One
Disturbance total
includes any
disturbance. Disturbance
Excludes any total includesyanticipated
.Habitat
restoration any anticipated
.and/orrestoration
or
and(ortemp restoration or
ppt
temp impacts)
im act amount temp impacts.
amount
Dredge ❑ Fill Both ❑ Other ❑
1 ��
Dredge ❑ Fill ❑ Both ❑ Others
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge.❑ Fill ❑ Both ❑ Other ❑
Dredge [] Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ .Fill ❑ Both ❑ Other 0
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both [) Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other.[] .
Dredge ❑ Fill ❑ Both ❑ Other ❑
i
Dredge ❑ Fill ❑ Both (] Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

Payment Proccessing Confirmation
Date Received 2/2/2017
Check From (Name) Allied Marine Contractors Inc
Name of Permit Holder John Lewis
Vendor
Check Number
Check amount
Multiple Permits
Major/Minor
First Citizen Bank
$1, 400.00
Yes
Permit Number/Comments GP 6798aD, Permit Fee $400
Receipt or Refund/Reallocated TM2805D

P�5 �4 44,_
w �,
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date o? -r-2 -- / 7
Name of Property Owner Applying for Permit:
Mailing Address:
r �/fCL��h<—
I certify that I have authorized (agent) R 1 / to act on my
behalf, for the purpose of applying for and obtai ng all CAMA Permits necessary to
install or construct (activity)
at (my property located at)
109,3
This certification is valid thru (date) ` 21' 13% — / 7

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner.
Address of Property: t 2 .3
(Lot or Street #, Sbim6t or Road, City & County)
Agent's Name #: -a Mailing Address: I Z <5�
Agent's phone #: 1' i a 3V -7,Z 4S 5 tw,Z g y y
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 proposing. A description or drawing with dimensions must be provided with this letter.
v/ I have no objections to this proposal. I have objections to this ro osal.
P P
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. Contact information for DCM offices is
available at http:lAvww.nccoastalmanavement.net/web/cm/staff-listing orby calling 1-888-4RCOAST.
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. (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
Print or Type Name
(Riparian Property Owner Information)
S' cur/e
Print or Type Name
164 44A' ,521
Mailing Address
Mailing Address

■ Complete items 1, 2, and 3. A. Signature
■ Print your name and address on the reverse X �,'; (- _ _ j El Agent
so that we can return the card to you. i""�"'�" ❑ Addressee
■ Attach this Card to the back of the mailpiece, B. Received by (Printed Name) C. Date of Delivery
or on the front if space permits.
1. Article Addressed to:
� U( ►3 -,-""-5
6 q 1 19",h- - C-t-sWe& Rp,
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Service Type
❑ Priority Mail Expresso
I
I I
I
I III'I
I II
I I
I
I
III
I II
I I I
I
❑ Adult Signature
❑Registered MallTM
❑ Adult Signature Restricted Delivery
❑ Registered Mail Restricted
9590 9402 1883 6104 3421 14
'Certified Mail®
O Certified Mall Restricted Delivery
Delivery
❑Return Receipt for
❑ Collect on Delivery
ElCollect on Delivery Restricted Delivery
a e.9ll
Merchandise
Signature Confirmation TM
❑ Signature Confirmation
2. Article Number (Transfer from service label)
7 015 1730 0002 1608
8061 it Restricted Delivery
Restricted Delivery
PS Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt

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