68057D - Oak

NC Division of Coastal Mgt. Habitat Impact Computer sleet
Applicant: Tb),/\JA Permit #:
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.
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
11 temp impacts)_amount
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
Dredge ❑ Fill Both ❑ Other ❑
Dredge ❑ FiN Both ❑ Other 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 0 Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: --fow)h 9 0A 1�a Ll
Mailing Address:
Phone Number:
Email Address:
I mdoo t �•
�-A
(�ty - 2a1, �3vCn �
I certify that I have authorized / b/No v io
Agent /Contractor
��11 �
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits bll\vnecessary for the following proposed development:
�)c
1 -__---j r
-/ �
at m property located at cud
�`r�ei� 1�1,� t5� J
in County.
1 furthermore certify that 1 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:
SiQgn�ature
Gcwe 1�1
rint or Type ame
Title

ADJACENT RIPARIAN PROPERTY OWN_ER STATEMENT
I hereby certify that I own property adjacent to�0�� C 4
t (Name�QfI PIro arty Owner)
property located at �c �-Y- - e � � l� v J �;G
be �.-G�..L� (Address, Lot, Block, Ro d, etc.)
on `
in c_'�5�� , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above location.
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)
,.
cno�
y
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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.)
�r.
-/,�— I do wish to waive the 15' setback requirement.
l I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
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i
iv lure
CIL
PriSolori l le[ -PAA "br .

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �Lc>r"'N Ck c)a� I
property located at (Name_ of Pro�ertGwe�r)
Gl�� (Address, Lot, Block, Ro d, etc.)
on i
in �iZ�� , N.C.
(Waterbody) (City/Town andlor County)
The applica t has described to me, as shown below, the development proposed at the above location.
�.� 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)
r -41- -4'- o
.
LOCO'
J,wall
, -'�01h
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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, y u must initial the appropriate blank below.)
TI do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information
Owner Information)
�Cr tur
�nh\er, _ L1.0
Print or 7 pe Name
5oa � ' (' -N�)kUA ISE 4,1

ADJACENT RIPARIAN PROPERTY OWN>=R STATEMENT '
hereby certify that I own property adjacent to 0~--------- �ert
y (Narsie f Prapert�w�)
property located at - (Address, Lot, t31occ
on tC� City/Town and/or County)
(Waterbody)
The has described to me, as shown below, the development proposed at the above Ic
`= 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 descrlpdon below or attach a site dray
-"P' -'Y-
P�,t
(�v cpp• • `_S CCod
�(tC
�Cp0 6
t,,b2-
rrH1yCK ar-U I IUN
t understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be sf
minimum distance of 15' from my area of riparian access unless waived by me (If you wish
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.
Prbperty Owner Information) (Adjacent Property - periy Owner Information)
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