68097D - Rooks

CAMA DREDGE & FILL '618097 A B
GENERAL PERMIT Previous per mit#_
ElComplete Reissue E Partial Reii Date previous permit issued
�New - :Modification . , "411� 4 V.A J
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
RU19w attached.
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g permit may be required by: < See note on back regarding River Basin r
ocal Planning jurisdiction)

Applicant CA
Date: Z41
Describe below the HABITAT disturbances for the application.
All values should match the name,and units. of measurement found in your Ha tat code sheet.
--
TOTAL Sq. Ft. FINAL TOTAL Feet FIN Sq. Ft. (Applied for. (Ant
(Applied for. (Anticipated final Disturbance dtsti
U' ance.totAl disturbance.
DISTURB TYPE Dist rb total includes EX6
Habitat Name' Choose One inciddes any Excludes any any anticipated rest
anticipated restoration restoration or. tem
restoration or analor temp
p),
temp impacts) impact amount terrip irn actsafri(
(4) Dredge [I Fill El Both ❑ Other
Both ED] Other n
Dredge Fill El, Both El other
Dredge [I Fill Both .11 Other D
Dredge ❑ Fill 171 Both El Other 171
Dredge F1 Fill M. Both D Other .[I
Dredge. 171. Fill El: Both ❑ other EI
Dredge El Fill El 'Both [I, Other I!

AGENT AUTHORIZATION FOR C WA PERMIT APPLiCAT1ON
Name of Property Owner Requesting Permit;
Mailing Address: ` ` " '"' "'
Phone Number: q 10 333 l'i'7y i ou Q • 3�1 •� Sl_�
Email Address:
I certify that 1 have authorized -knc I nrle4+
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: WL D Vn6f f Ol1f1C���ec�C�
at my property located at l�Yl
I 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 then agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
property Owner Information:
'oai5s
This certification is valid through 1 1

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to r(t f VYW;`S� 1` s
JName of Property O%.....r)
property located at Z
(Address, Lot, BI k, Road, etc.)
on in I N.C.
(Waterbody) (City/Town and/or County)
The appl9pt has described to me, as shown below, the development proposed at the above
I cation.
r 1 have no objection to this proposal.
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)
VV
i� ��'lf� -eY Lt T �� i r
WAIVER SECTION
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 yo 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 Owner Information)
Print or Type Name
n 6 of Orin u �Urm
Information)

� b Gnkd u.� :c.k L►,.
r �'
15'
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ADJACENT RIPARIAN PROPERTY OWNER ST TEMgNT
i hereby certify that t own property adjacent to 4nnirck ame of ,Property �Is�}
property located at
(Address, Lot, B Road;etc.)
on V%N0 „� tninto
d in 10n%C1-A . N.C.
iwaterbody) (City/Town ad &or County)
The applicant bas described to me, as shown below, the development proposed at the above
I have no objection to this proposal.
1 have objections to this proposal.
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing -development must fill in description below or attach a site drawing)
'y7t e
to
WAIVER SECTION
I understand that a pier, dock, mooring ~, boat ramp, breakwater, boathouse, rift, or groin
must be set back a minimum distance of 19 from my area of riparian access unless waived by
me. (If you wish to waive the setback, you mast Initial the appropriate blank below.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the IF setback requirement.
(Adjacent Property Owner,
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