68098D - Riff

K1CAMA / ❑ DREDGE & FILL
PENERAL PERMIT
ew ❑Modification []Complete Reissue
8098 A B
�, Previous permit #
❑Partial Reissue Date previous permit issued
prized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
Rules attached.
nt Name / �— �� Project Location: County
y .4 Street Address/ State Road/ Lot #(s)
State �� ZIP ZYY1?O I M iM &' hSou �.?IC . , C OA'V M .
E-Mail Subdivision
zed Agent E/ti�l jI�/�Ey� City g —4 ZIP 2r;-4
i ElCW kEW ,PTA ❑ ES ❑ PTS Phone # ( ) River Basin !�i
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ N/A Adj. Wtr. Body C.i� �i-�y nat .
❑ PWS:
yes elho PNA �O no Closest Maj. Wtr. Body
,f Project/ Activity
Eck) length
latform(s)
mgth \ V—
imber A-
id/ Riprap li
g distance <
ax distance
hannel
ibic yards
mp
t
zi
ie Length r� /00
not sure yes
Ium: n/a yes no
yes
Attached: yes no
ng permit may be required by:
Local Planning Jurisdiction)
�" s /mil hey Cam.
(Scale: r -�
❑ See note on back regarding River Basin r

NIC Derision of Gon§tal :Mgt- Habitat Impact. Computer Sheet
Applicant:
Date:
Describe below the HABITAT disturbances for the application,
All ,rat, ohnilld match the name. and unb of measurement found in. your Habitat code sheet.
TOTAL Sq. Ft.
FINAL. Sq. Ft.
TOTAL Feet
Fit
(Applied for.
(Anticipated final
(Applied for.
(Ar
DISTURB TYPE
D ISTURB
Disturbance.total
includes any
disturbance.
Excludes any
Disturbance
total includes.
dis
Exi
Habitat Name
One
Chooseanticipated
restoration
any anticipated
res
restoration or
and/ortemp
restoration or
ten
tem ii<m1' acts
Im acf amount
tern im acts
ain
1 v
Dredge ❑ Fill ❑ Both ❑ Other
Dredge C] Fill ❑ Both. ❑ Other ❑
Dredge ❑ Fill ❑ : Both ❑ Other ❑
Dredge ❑ Fill ❑ ` Both ❑ Other ❑
Dredge ❑ Fill C1 Both ❑ Other ❑
Dredge. ❑. Fill ❑ . Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other []

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Vq
/ � `Permi�tKlFi-
Mailing^ Address: A i�,4 5A l L, bk
Phone Number:
Email Address:
I certify that I have authorized
E
6Z1�)3y9 -53,-�0
Agent / Contractor
✓2 R 1 ('l L
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
in County-
/
furthermore certify that I 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:
/ Signature
V - f�
f Print o1 r ,TyljpeName
W JC e7 0 J
Title

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to r 'c FF 's
(Name of Property Owner)
property located at .`A ;
(Address, Lot, Block /SRoad, etc.)
on _ cw �rM-r�C in , ' -e4- Pv� t'tM, N.C.
( aterbody) (City/Town and/o County)
The applicant has described to me, as shown below, the development proposed at the above locab
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, breakwater, boathouse, lift, or groin must be set bac
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to w,
the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
RY 1 do not wish to waive the 15' setback requirement.
(P perty Owne Ind7ation) (Adjacent Property Owner Information)
Si ature /� - Cik�Si re C
Print or Type Nam Print or Type Name
1/">a M A►���AIr �Q

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:
Or
(Lot or Street #, Street or Road, City & County) Agent's Name #: lftne-tf Ma Y I n e, 0,61 + Mailing Address: -15A Grr
n no+ Lan e
Agent's phone #: "I ' 1 ri. l' 7 `f 15 5 n ea_ �e NC V 4&0
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing_the development
they are proposing. A description or drawing with dimensions must be provided with this letter.
l 1 have no objections to this proposal. I have 0-jections to this proposal.
It you have objections to what is being proposed, you must notify the ;Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM vices is
available atAtW.,# vww.nccoastalmanagernent.neM,-.. m/staff-llsVt orby calling 1-888-4RCCA,ST.
No response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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.
(Prnnerty Own luf ation) (Adjacent Property Owner Information)
Si tore Signature
Print or Type Name Print or Type Name
l r1/L AAA 7 A 1 .�. .,

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