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NC Division of Coastal Mgt. Habitat Impact Computer sheet
Applicant: G� G
Date: C-7
Permit #: (i�/6 g() 43
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
temp impacts)
FINAL feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
Dredge ❑
Fill ❑ Both ❑ Other
U
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 ❑ .
�Drr�dEge[]Fill
❑ Both ❑ Other ❑
Dredge ❑
Fill ❑ Both ❑ Other ❑
Dredge ❑
Fill 171 Both ❑ Other ❑

Beverly Eaves Perdue
Governor
ALMA
'North Carolina Departme6t of Environment and Natural Resources
Division of Coastal Management
Braxton C, Davis flee Freeman
Director Secretary
AGENT AUTLJORIZATI N FORM
Date: G
Nam_ _ e of Property Owner Applying for Permit: Name of Authorized Agent for this project:
Owner's Mailing Address:
c4wu i
Phone Number t&) & -MI 1
Agent's Melling Address:
= = 2798 Sea Vista Dr.
=�Supply, NC 28462
UNSR
Phone Number ao,
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the totlovWng (activity):
For my property located ata't a G
a2-
This certification is valid thru (date) 8 `J
Property Owner Signat re Date

. �". . . . . . . . . . . . . . .
a tt o jacen 4, . i- lei
me of Proporty
Owner}
9
(Address,Lot,BC 1600
In N
Werbody).'3, County): .
development- propos
ed
IV
n to this is oSai.
. . . . . . . . . . . . . . . . . . .
eve Objections to this proposal,
PMP T
-NING OF PROPOSED oE * yFL-O
Ieividuiail' " v . 6 m6 Mfin description below 6AWk; dra.win
44,1.,
7A Y-x Az,
. , i
:A:,: IX7-
ilk
&
h to way 11's- 6
ish to waive the 15',toth ack requirement.
(A ac,en
§
34-
0
Cif Y/S
ail addres, 'N-t-
Telephb
ner n orm stlon) 0 iL
WT

olool) DOLy

"arty located at
erY + Add N.c:
�thF) RY gwn Old/0 ut ty)
The spplident has d to no"as shown fir, the devetopmei'tt proposed atthe above
lo Wn:..
i have no objedtieon to tha pt�at
i have objections to this p aposai.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
~proposfW development must frll i descripdoa below or attach a stte di -swing)
ell
t.•� ihot.rg'pier,dock;:rRioflrlM�i4�T�M'
Pi, gs boat ratttp bmsKwater, boathouse, ,lift, br groin
mug be: set back a mWmum distarme of 16` f yr my am pf.dper a access unless waited by
me, If wish to wal 8etba0c,yct -'Must InMal.the appropriate blank below.)
i do wish to waive the fE` s*tback requirement.
.1 do notwIl to wove the 1t t*Wirement.
(PrbY'flwtOn}.y
Att
f>` G t[G1i
R nl r T Name ,. '
Address MA
C p to i p
elf C4
Tel t* Number om It-ut Telephone Numberl email address
Dam Datet,

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