68030D - Miller

R�k 3.� -11 _'.,,.
CAMA / ❑ DREDGE & FILL, ? A B
Previous permit #
a.ENERAL PERMIT
, lew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources
',oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC�[:1 Rules attached.
Name / Y \ a � �/` N `t1�� Project Location: County ns VN 7
l �� yn Street Address/ State Road/ Lot #(s)
�A—
State &f ZIP(` j 1) i -Mail Subdivis�io�n,
ed Agent �[1>��\/1 ,Cgit(y� ti_ �� �NKTl��� ZIP
❑ CW XPTA ❑ ES ❑ PTS P'h2Sr'�eNP — 4 3 ' River Basin LV K
❑ OEA 'LJ HHF El IH ❑ UBA ❑ N/A Adj. Wtr. Body (nat h
❑ PWS:
Closest Maj. Wtr. Body (A/(A/
yes / no PNA yes / no
f Project/ Activity
C-1 o 00 Yt
,ck) length
atform(s)
Platform(s)
)ier(s)
angth
amber
id/ Riprap length
g distance offshor _
ax distance offs re
:hannel
ibic yards
ine Length
Drium: n/a yes
yes o
r Attached: (9 no
ding permit may be required by:
2 CAC.,' ❑ See note on back regarding River Basin

ime) Permit
Holder
;hael H5
er Construction BB&T
Number I amount k I Number/
N. Comments
GP SF rct.
Refund/Reallocated
1886 $200.00 68030D 3554D .4L-..

WA
waLT g
N431 R
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
3everly Eaves Perdue Braxton C. Davis
governor Director
AGENT AUTHORIZATION FORM
Date:
ime of Property Owner Applying for Permit:
7 /C'<--C S - 17)1L 65&—
vner's Mailing Address:
one Number 14
Dee Freeman
Secretary
Name of Authorized Agent for this project:
Agent's Mailing Address:
H5 Construction, LLC
=HS= 2798 Sea Vista Dr.
COASTSOCTION
Supply, NC 28462
Phone Number c
artify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Permits necessary to install or construct the following (activity):
AJ 6(f� ,
r my property located at 45Z 6AJ;!i5� 9?0*00 57;96�
is certification is valid thru (date
t. _ _/I
Property Owner Signature
Date

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: �n,z1� o� �/1/1 I Permit ##: �b
Date: Cr 2�6 3 �2 0 (�
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
TOTAL Sq. Ft
(Applied for.
DISTURB TYPE Disturbance total
Choose One includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excudes any
restoration
and/or temp
impact
TOTAL Feet,
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
rI r� J
v V
Dredge ❑ Fill ❑ Both ❑ Other j;�
amount)
g J
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 ❑ Both 0 Other ❑
Dredge 0 Fill 0 Both 0 Other 0

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to /`V1 r! M / Lt- l 's
/5-6 �� !amp pf Property Owner)
property located at 111 /'/ �`
(Address, Lot, �I c.� �oad,
on , in ti� • �1 L `L N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
locati./
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)
AF�;R br E 1-V—I 29 4?o4T u�l- -o9*2) 1W) 4 10y-lx L4 '
/2-0,47 SIG 2)VG4, .j5�X T-SAlsio c! 7D Lo/ S iZ E
WAIVER SECTIOW
I understand that a pier, dock, mooring pilings, boat ramp, 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)
uc ��utuyi c� may, ; j
iij
�,�p� fQ�'e / ✓at C�i y� aSCyv
to r Type e�O�I i'JTG X
Ma"ing L4ddres �� ' r��Z'MAWng 2 dress � V, � . A/", �� Soy

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 61(u rt c(�, -�. / f ► i LL0—(,— 's
/ ( �4►�ame of Property Owner)
property located at ( 6 to I_a L i�Gyo �7
(Address, L ot, o oad, cj
on , in Vim- 4-- , N.C.
(Waterbody) (CitylTown and/or County)
The applicant has described to me, as shown below, the development proposed at the above
to atio
,f 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)
9YUS7-1,V9 9&97- 01fluZ) 00W /9/dux S"`w
�GDl�??r1lG 1'�V(f�C 9A/5'/i0A/ 7L lro� S iZ
s7;%-67.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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)
��AT�meC,,, ,, � Prin; y e am ,
Xe AW � la ' hg Add re qC �