68022D - Savidge

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: cr�av Cj Permit #:
Date:
l
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measuremen
found in your Habitat code sheet.
TOTAL Sq. Ft. FINAL Sq. Ft. TOTAL Feet FINAL Feet
(Applied for. (Anticipated final (Applied for. (Anticipated fins
DISTURB TYPE Disturbance total disturbance. Disturbance disturbance.
Habitat Name Choose One includes any Exdudesany total includes Excludes any
anticipated restoration any anticipated restoration and/
restoration or and/or temp restoration or temp impact
temp impacts) temp im acts amount
Dredge ❑ Fill ❑ Both ❑ OthernVy
unt
1 C?Jv
Dredge ❑ Fill ❑ Both ❑ Other [I
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge. El Fill ❑ Both n 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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑ .
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both Q Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

Payment Proccessing Confirmation
Date Received 2/2/2017
Check From (Name) Allied Marine Contractors Inc
Name of Permit Holder Thomas Savidge
Vendor
Check Number
Check amount
Multiple Permits
Major/Minor
First Citizen Bank
5286
$1,400.00
Yes
Permit Number/Comments GP 68022D, Permit Fee $200
Receipt or Refund/Reallocated TM2805D

4
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 l - 1 ':T - 1 -7
Name of Property Owner Applying for Permit:
Mailing Address:
2 -L- /IA L L A-j-�
L elm-
I certify that I have authorized (agent) k4 itl-A17,,1'to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) `F tin, �' -, S L
at (my property located at) -L- Z-- 11'�c �-� A� ()1•� 0 ez� 'J L ,Z 4 ��
1.
This certification is valid thru (date) L 3 l Z
- fir- l-7

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to p /h jc, v 's
(Name of Property O ner)
property located at / 22- /YIGL 4-�qZ � -
(Lot, Block, Road, etc.)
on ���la,Q , in o p�ig( , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: Mailing Address: 9v
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.) / y
I do not wish to waive 12��/ Kf�'
_ 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)
(Riparian Property Owner Information)
Mailing Address
` Signature

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to I D �a -,/! Gt e, is
(Name of Pr erty Owner)
property located at I ZZ MG Le-4
(Lot, Block, Road, etc.)
on 00,/1 A, � , in % DA`7��' � &w�k , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: 11036,7 a (�5 Mailing Address: V- r0lcP (!!�f
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
�'✓ ` 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)
f�
��-L���
Mailing Address ..-)
(Riparian Property Owner Information)
Signature

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