69406D - Smith

CAIMA / YDREDGE & FILL
"ENERAL PERMIT
New Modification ❑Complete Reissue
❑Partial Reissue
A B
Previous permit #
Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources f
oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC {� LI I I t Rules attached.
Name 4� ` Yt tit s Project Location: County N Q h" I {es6 CII f Y
Ma Q Hj o V1 1%'VC. Street Address/ State Road/ Lot #(s) 2 (-S ,tip i.
it State ll C ZIPNLGM o t� x 'LA"A v "E
'CJ E-Mail Subdivision C Y tL't ilk ' A VN
L
ed Agent V1T 0 I K City (/V 1 �YL'� 1 rTy 1, ZIP
❑ CW XEW )(PTA ES XPTS Phone # ( ) River Basin
LiOEA ElHHF ElIH �UBA ❑ N/A Adj. Wtr. Body M �1'li1 19( 1 l? �C-K hG J A2 /I
Closest Maj. Wtr. Body
yes / no , PNA es no
I Ll
f Project/ ActivityL � h�� l��V'cCci �� t
:�iA [I if tI (Scale: ��f
,Ck) length
ine Length +/— JU
not sure yes no
ding permit may be required by:
❑ See note on back regarding River Basin

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: Sw t`y I
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
%�r.FEW. e
N
I Contractor
Olio -
,T:
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
i C ��(�(,
necessary for the following proposed development: ♦�� S c''
at my property located at 22�a Mafsy) Om ►JY•
inw�N Wnoy'(- County.
1 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
Print or Type Name
qef-
'Min

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to aw J � ik1aY le-� ,c'm j-Ch 's
(Name of Property Owner)
property located at 22_ Nla.rS1J Hp►�, flr
(Address, Lot, Block, Road, etc.)
on t�
C nl'n L' � c n �',anm in I Ld1L WMOWI-, N.C.
(Waterbody) (Cit own and/or County)
The applicant has described to me, as shown below, the development proposed at the above loca
/311 t" 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 drawirn
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set be
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to v
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) (Adjacent
Signalwe Signature
} t wiry lit
Print or Typ Name Print
Owner
141f / it "?A

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Vd,v cy\ay ( ,�W'4y1
(Name of Property Owner)
property located at N rS Vl
(Address, Lot, Block, Road, tc.
on W,AfV, ' ('l.1Ml , in W�► 61i ,W V-L , N.0
(Waterbody) (ity/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above Ic
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 draH
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish t
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)
— vAk-'
SignaturK ,
Print or Type Ndme
\AA K) �--iv V VW
'acent Prop rty wner Information)
t or Tie Name

.3'
WOOD x
BULKHEAD I
x
METAL
CONCRETE
BULKHEAD
'j'.o
•s
WOOD x
BULKHEAD
x
METALI
;:40.00'
LP.&
P.Q.L.
I.P.a
P.O.L.
Z0NE AE �
0a 10)
• T k
ammo Noun
Aj-eA_J R-.(Lfe
LOT 57
14 7O0* Sq.Ft.
POD!
Pou
.rrw +ram =
/rfT/
543#42'00"i_ 105- 000
000 LOT 57
t 4, 700t Sq.Ft.
ZONE AE � P014
(EL 10) PoLI
.r .w�

NC Division of Coastal Mgt. Habitat Impact Comp
Applicant:
Date: `��I
Describe below the HA ITAT 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.
(Anti
Habitat Name
DISTURB TYPE
Disturbance total
includes any
disturbance.
Excludes any
Disturbance
total includes
distL
Excl
Choose One
anticipated
restoration
any anticipated
rest(
restoration or
and/or temp
restoration or
teml
temp impacts)__impact
amount
temp impacts)
amc
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge 19Fill ❑ Both ❑ Other ❑
�O
Dredge ❑ Fill ❑ Both ❑ Other 14
VD
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other 0