69178D - Purinai

AMA / DREDGE & FILL 1
3AENERAL, PERMIT 7.L4 l� Previous permit# A B
flew —Modification ]Complete Reissue []Partial Reissue Date previous permit issued
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rized by the State of North Carolina, Department of Environment and Natural Resources ,+
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
r i P Rules attached.
t Name d !/` A t Project Location: County �A,0r�/2-
00 , R- , Street Address/ State Road/ Lot #(s)
u�0 ,J State/i C.. ZIP 2 '7"3 *ti5-
fU )� •Zl� �E-Mail
ed Agent k V t 4 V/ A AA_AMJ_
❑ CW 'TA ❑ ES ElPTS
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❑ PWS:
yes no PNA yes no //
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city ZIP ZYrf
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•ocal Planning jurisdiction)

NC Division of Coastal Mgt. Habitat Impact Coml
Applicant: �T v ` L;
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.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FIB
(Applied for.
(Anticipated final
(Applied for.
(An
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disc
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
res-
restoration or
and/or temp
restoration or
ten•
temp impacts)
impact amount)
temp impacts)
am
-2 -
v
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 ❑

A�A
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date 15-- �F-17
Name of Property Owner Applying for Permit:
Mailing Address: /
01
g7 y
I certify that I have authorized (agent) 411 to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) A-Q- I
//
at (my property located at) ! d 8V�JX—
This certification is valid thru (date) l Z - 3 f -
e,
Owner Signature
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGS/BOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to _yy I, a J Jf + nu s
(Name of Property Owner)
property located at / 0 9
(Lot, Block,
U,e
etc.)
on Cq N AL , in I JL6ic,L-� , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: Ito 3e Z Z l6 '1� Mailing Address: Z 4y'rAck Gt
i rwj/5 k4a wc- 28KK3
fie has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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.) /1
I do not wish to waive
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
Mailing Address
(Riparian Property Owner Information)
Signature

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to 71 6rw5 Q . Br000'e is
(Name of Property Owner)
property located at oru,k QW Q
(Lot, Block, Road, etc.)
on , in , N.C.
(Waterbody)
(Town and/or County)
Applicant's phone #: q f 0- 2r19-Io33 (o Mailing Address: 1215 �—��4-64 D r
lLa cams UA C. 2835Z
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
V I do wish to waive that setback requirement. "M
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
(Riparian Property Owner Information)
Mailing Address
Signature