67175D - Muter

IA;AMA / ❑ DREDGE & FILL l / )-/b
ENERAL PERMIT Previous permit#
❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
-ized by the State of North Carolina, Department of Environment and Natural Resources f'
.oastal Resources Commission in an �area of environmental concern pursuant to I SA NCAC G)
t Name 1 1 Rules attached.
S
V Project Location: County OSL jA r K
In) Ki. Street Address/ State Road/ Lot #(s)
c 6✓I D in Stat'zip r�� 1t ' 0�-A ' 1
l�► ) -93y0 E-M it Subdivision 1 (C )r (
ed Agent L Gd City USA Iy ZIP �� 1
t CW ;KEW eTA ❑ ES ❑ PTS Phone # ( ) //'f I'M N o 1 River Basin❑ OEA ❑HHFH ❑ URA ❑ N/A Adj. Wtr. Body VDT Q7J 611Y 9W-1 n r
❑ PWS:
yes no) PNA Ness)/ no
Project/ Activity (,
:k)length_ 14
itform(s) 11 X 10
Platform(s)13�)( I&
igth
nber
I/ Riprap length
distance offshc
x distance offsh/
annel
■00_001001 ■
■Ili■� 31 0Imm NINE
I ■■
■■■iE■■IlNIM
■mmA mm
■■v, 11,
■■0
.■■i ■
IN■':yIL"�'illH�l Cl�
lmll
Closest Maj. Wtr. Body
roA
❑ See note on back regarding River Basin
1 r1 LI 1t_� - i_iJ,

'NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: 130 v\, A w/ c
Date: 0 0(
/ 40
Permit#: v-7 (-7 S
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 im act
FINAL Sq. Ft.
(Anticipated final
disturbance.
. Excludes 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
Dredge [IFill [IBoth ❑ Other
amount)
Li p
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 ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

RCbENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
Dee Freer
Sege
AGENT AUTHORIZATION FORM
Date O -
Name of Property Owner Applying\ for Permit. Name of Author
ized AAgent for this project:
Owner's Mailing Address
Phone Number
Agent's Mailing Address:
Phone Number 411/ 3 -`V
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
Afsxa- ll ibc . 164
to install or construct the following (activity):
(my property located) at
This certification is valid thru (date)
Date

N
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to o krV /Li) 41e i'L s
/� (N me of Property Owner)
property located at 9 Y/, (g mill
(Address, -Lot, Block, Road, etc.) i
on C dV, in " C.
(Waterbody) (Ci ow and/or County)
The applicant has described to me, as shown below, the development proposed at the above
AV
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)
4Q Y\q W
11:r
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)
A,zd
'ignalure
- Lakve-
(Adjaceilit Property Ow r Information)
Sign u

M
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to J cl
(Name c f Property Owner)
property located at S C
(Address, Lot, Block, Road, etc.)in
r'
C.
(Waterbody) (Cit ow and/or County)
The applicant has described to me, as shown below. the development proposed at the above
locatic„n.
X I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(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 groin
must be set back a minimum distance of 15' from my area of riparian access unless waived by
me. (Ifyouwish to waive the setback, you must initial the appropriate blank below.)
1/ I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
. •i�>>ruttu•c
Print or Type Name
/96)7 k„rh.
(Adjacen
er
Pnrt
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Maitina

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