69200D - Puckett

,LAMA / 1XIDRIEDGE & FILL Q
A B
WNERAL PERMIT Previous permit#
+4ew ❑Modification []Complete Reissue El Partial Reissue Date previous permit issued
-ized by the State of North Carolina, Department of Environment and Natural Resources f1
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
I ` ❑ Rules attached.
t Name { \I("� t/1(,� O \� Project Location: County�,l.ti q�'
L
()' U 9, �1 -h I
V State, ZIP
((( ( _ - �� E-Mail _ �---•-
:ed Agent
❑ CW •ikEW A NES XPTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
PWS:
yes / rho; PNA yes /
f Project/ Activity
ength
ember
�d/ Riprap length _% 110�_
ig distance offshore I
iax distance offshore 7-
in. Length V
not sure yes
orium: n/a yes
s: yes
r Attached: ding permit may be required by: � Uk/Y� 6� ' , � (5tCf See note on back regarding River Basir
Street Address/ State Road/ Lot #(s)
Subdivision-
City— - 1+0 i-r �f ai- (A ZIP
Phone #'T(q j V) 5 Ll `sj V River Basin Ll"
Adj. Wtr. Body_____( U (nat /
Closest Maj. Wtr. Body
(Scale: 1

NC Division of Coastal Mgt. Habitat Impact Coml
Applicant: C to-OA(,t" /t( #' (� 1
Date: �� /A / o
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
FI?
(Applied for.
(Anticipated final
(Applied for.
(Ar
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disc
Habitat Name
Choose One
includes any
Excludes any
total includes
Ex(
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
ten
temp impacts)
impact
temp impacts
am
V U
Dredge ❑ Fill [ Both ❑ Other ❑
D
amount)
u v
Dredge ❑ Fill Both ❑ Other ❑
Q
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

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is her" auftwt ed to a& an nor
ra adain s.*-CAMA par * rnequwW for ttte pmp&W fs'ed belwm The a rit 1 1=1i x is by*
descib" in the Vachsd
ION OF PROJECT:
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MAC ADDRESS:
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PAGE 01
?/07/2004 19:20 9108429806 %n
Name of Individual Applying For Permit:
Address -of Property: P, ` �•.G��� `�2 ' "_ZX �
(Lot 'or 5treset gtrett ox Road, C ty & County)
I hareby certify that I own- property adjacent to the above -
referenced proPerty_ The ind3_vidual applying for this permit has
described to me as shown one tha a-ttachad drawing the davelopvent
they ar* proposing. A description or drawing, with dimensions,
should be provided with this I*ttQr-
I have no objections to this proposal.
IMTyZR 8 MM
I understand that a pier. dock, Mooring P111ugsI braa]cwater, boat
hou
se, lift _ gust be set back a minixmm distance Of 15'
hh,
s unless waived by me. (If you wish
fouaia ay axes of riparie�n acces
to Vaive the setback, Y fini al the appropriate blank
below_)
I. ,do wish to waive the 15fsatback requirement_
I da nod wish to waive the 15'setback requirement.

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