54459D - Riccardi

CAMA / C DREDGE & FILL
3
GENERAL PERMIT $'
4New -Modification []Complete Reissue ❑Partial Reissue
)rized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC_
it Name
State / ZIP Z7"' 9
�W)11Z Fax#( )
red Agent % a 4 " C.-.-
7 CW ❑ EW ❑ PTA "S '❑ PTS
- OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
PWS: ❑ FC:
Project Location
Previous permit #
Date previous permit issued
G? N 1 / Oc)
EP Rules attached.
County j'1S r w
Street Address/ State Road/ Lot #(s)
t,o 4- ;� C i'W tab c k
Subdivision
City DAt� ' 5 ZIP
Phone # ( River Basin `-4
f f
Adj. Wtr. Body
yes / no PNA yes / no Crit.Hab. yes / R � Closest Maj. Wtr. Body
,f Project/ Activity 614)1�rG�
(Scale:
> ) length_
n(s) --
r(s)
mgth s --
imber
id//�p length /
g distance offshore —Z _
ax distance offshore
^annel -
rp.
ise/
ie Length 9 'v
not sure yes r4
;s: not sure yes
-ium: n/a yes no '
yes
Attached: yes
ng permit may be required by:
w
❑ See note on back regarding River Basin ri

NC Division of Coastal Management
Cashier's Official Receipt
p c
Received From: �
Permit No.:
Applicant's Name:
Project Address:
Date:
$
4218
Check No.: PD 4
County:
Please retain receipt for your records as proof of payment for permit issued.
Signature of Agent or Applicant: Date:
U
Signature of Field Represen Date: _

NC Division of Coastal Mgt. Habitat Impact COMF
Applicant:
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
FIN
(Applied for.
(Anticipated final
(Applied for.
(Ani
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
dist
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
rest
restoration or
and/or temp
restoration or
tern
temp impacts)
impact amount)
temp impacts
am<
(�
Dredge ❑ Fil Both ❑ Other ❑
-
Dredge ❑ Fill ❑ Both ❑ Oth!pq
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge 0 Fill ❑ Both ❑ Other ❑

Pilings and 100re
910327-6353 p.1
AQENT AUTHORIZATION FOR LAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: (Jae, d-,
Mailing Address: 60;i
Phone Number:
Email Address: P, C Ccx (Oi r 1'VlCLL o wr
I certify that I have authori2ed
gent I Cortrartor
to act on my behalf, forthe purpose of applying for and obtaining all LAMA permits
necessary for the following proposed development:
41— 17 ,
at my property located at
in County-
1 furthprmnre codify that I am authorized to grant, and do in foct grant permission to
Division of Coastal Management staff, the Local Permit Officer and (heir agents to enter.
on the aforementioned lands in connection wtih evaluating information related to this
permit application.
Print or Type Name
True
Ia
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to %� `J 's
(Name of PropertyOwner)
property located at /�T %" "Or
(Address, Lot, Block, Road, etc.)
on , in �j'/L. , N.C.
(Waterbody) (City/Town nd/or County)
The applicant has described to me, as shown below, the development proposed at the above
to i
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)
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.)
L ` I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Properl a %I(nfon '
Signatu
Print or Type Name
(Adja t Prope Ow r I gtion)
���
Signature*
Print or Type Name
J J-- 1 .4. .

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to %�?�`� / ,s
property located at
Gw 3 d�t 4 61,,,(JName of Property Owner)
(Address, Lot, Block, Road, etc.) N
on , in , N.C.
(Waterbody) (City ow ndlor County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
J l ! 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)
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 On Inf atio (Adj ent Property Owner 1 , ormation)
Signature Sio for e _ ]
Print or Type Name Pri t !LT e me
rl
Mailina Address _ Mailinq Address - I-_ . , .