69073D - Simmons

JCAMA / ❑ DREDGE & FILL A B
1"ENERAL PERMIT Previous permit #
New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
Ized 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 0 —
�. El Rules attached.
t Name 1, t'\n d A i'K 6^C-K s Project Location: County N
t;1L' 1 ? jOtopri1c NET t: At- Street Address/ State Road/ Lot #(s)
(. ro I OP-T IVN State w-i ZIP ��'l 'A
E-Mail Subdivision ���/
:ed Agent ! Pew� � � City PS� AP ZIP Z-�C "I ti
❑ CVN EW PTA ❑ ES ElPTS Phone # ( y"�"""' River Basin C
❑ OCEA 7 HHF /❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body A w� a
❑ PWS:
Closest Maj. Wtr. Body
yes Cnu,, PNA yes /I rrS
f Project/ Activity d2ly
Ock) length_
latform(s) _
Platform(s)
angth
Imber
t�l/ Riprap leng/tj'
g durance offshore_
ax dis(ance" offshore
:hannel X
use/ Boatlift
ne Length
not sure yes
>rium: n/a yes
yes o
Attached: no
ling permit may be required by:
1 . 1 pi-ina Inricrlirtinn�
(Scale: )
r
El note on back regarding River Basin

NC DIVIS10111 Oi (�Q�$$dl')Y3�6s 6EGlnraaud
�V4_
Applicant:
Date: v(
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,
for.
FINAL Sq. Ft.
(Anticipated final
TOTAL Feet'
(Applied for.
I'M
(An
DISTURB TYPE
(Applied
Disturbance.total
includes any
disturbance.
Excludes any
Disturbance
total includes.
disc
Exc
Habitat Name
Choose One
anticipated
restoration
any anticipated
resi
restoration or
temp im • acts)
and/or temp
Impact amount
restoration orterr
temp irfi acts
am,
Dredge El Fill ❑ Both ❑ Other
Dredge ElFill ❑ Both. ❑ er ❑
Dredge ElFill ❑ : Both .❑ Other FJ
Dredge ❑ Fill ❑ ` Both ❑ Other ❑
Dredge ❑ Fill Q Both ❑ Other C1
Dredge. ❑. Fill[]: Both ❑ Other ❑
:.; '
Dredge ❑ Fill ❑ Both ❑' Other

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit:
Mailing Address: ,
E_DP,
lam/ L � m � � G 1 c� T� i� • � . 2 � �{- � �
I certify that 1 have authorized (agent) fAl T j � pP�N to act on m}
behalf, for the purpose of applying for and obtaining all CAMA Permits necessar% to
install or construct (activity)
at (my property located at) / 4,3 q )<i A/ S 1 iV��N
L) 3
Na�s�4
This certification is valid thru (date) , 11"e C -20 , ;-D � 8
Owner Signature ` Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to eIV17dd s
12C� —T (Name ofproperty Owner)
property located at ��/ ✓ ` !t!f/ /S ��li°t�!<v�
lA! Address, tot lock, oad, etc )
on c F'K _ , in Y �GZ� Y.C.
(Waterbody) (City1T wn and/or County)
The applicant has described to me, as shown belowthe development proposed at the above
location./
V " 1 have no objection to this proposal.
I have objections to this proposai-
DESCRIPTION ANWOR DRAWING OF PROPOSED DEVEI OPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings. twat ramp, breakwater, boathouse, lift, or groin
fn s be set back a minimum distance of 15' from my area of riparian access unjess waived by
�m f u wish to waive the setback, you must initial the appropnate blank below.)
1
1 do wish to waive the 15' setback requirement.
1 do not wish to waive the 15' setback requirement
(Property Owner Information) ooia ent Property Owne Info mati ro
ref rK o tii—� -
Pri�nt �or r ame Prn orT e Na e
2,90 n �Ai lR� %G 3'r gQadrn ,Address , ing A iT s eG
Cit�/Stj( P(137 to © J
T�SS�horreNumber/emailaddre ' Tolenhone u. /email address
lkrte Dare
(Revised Aug. 2014)
'Valid for one calendar year after signature'

ADJACENT' RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify
ertit that f own property adjacent is / (Name of Property Owner)
property located at ✓ 1..5 d it
Address, Lot, ock, oad, etc.)
'T�t'Y Ya' _ in r s���_ N.C.
on (Waterbody) (CitylT wn and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION ANDIOR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I �xrderstand that a pier, dock, mooring pilings, boat ramp, breakwater boathouse lift, or groin
must be set bark a mirimum 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 blark below.)
i do wish to waive the 15setback requirement.
I do not wish to waive the 15' setback requirement.
)CIProuerty Owner Information)
`Valid fcr one :aierrdar year after signature'
(Adjacent Property Owner information)
nature"
Tint or Type Name ^�
Mailing A ess
C%Py tateT'
relephoft hLprnber / email addres
(Reviaed Aug. 2014)

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