68519D - Terwee

PCArMA / r-XPREDGE & FILL
GENERAL PERMIT
New JModification ❑Complete Reissue
El Partial Reissue
8519 A B
Previous permit #
Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources l ff 4
oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC �� I'1 �1 U Q 4 0 � !'� • ��
❑ Rules attached.
Name Cy Q Project Location: County41 h� �-Af C
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g permit May De requirea y:See note on back regarding River Basin
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ocal Planning jurisdiction) I - - - . , . , , ,, 1 , i

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oac McCrory
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North Carolina Department of �Rv,ro^ment and Natural Resources
N.0 Diwsior of Coastal Management
AGENT AUTHORIZATION FORM
Date '
Name of Property Owner Appl ng for Permit
Owner's Mailing Address
Email -------- ---
Phone i j,
John E.
S
Name of Authorized Agent for this progeq
Agent's Mailing Address:
19,01 K. (6 ,Z
— P+I --QC- 2$4 tQZ
Emaill �nr V S �rj l�f �, r7�c 1 4
Phone --
I cerVy that I have authorized the agent listed above to act on my behalf, for the purpose of appiyin4
for, and obt
all CAMA Permits necessary to install
For my property located at
the following (activity)
r

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a �� �id CERTIFIED MAIL RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIOWWAIVEI
Name of Property Owner: 2rQ, ��12 (
Address of Property. J ±:�
�,
(Lot or Street S. Street or rcoac, Uay 6 County)
Agent's Name #: Z1rCnf j AL zt!rl q MaitiN Address/G
Agent's phone
I hereby certify that I own property adjacent to the above referenced property.
applying for this permit has described to me as shown on the attached drawsng till
they are proposing. A description or dray r, with dirnenskiris. must be provided w
KP I havc no objections to this proposal. __ __ I havc objections to this 1
If you hove objections to what is being proposed, you must notffy Me Division of Cow liana
writing within 10 days of receipt of this notice. Correspondence should bo mded to 127 Ca
K2wington, NC, 28405-3845. DCU representadyn can also be conocted at (910) 7W7215
conskfe W the serge es no ob}ecdor► d you hove been noEERad by-Cerditd:W.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater. boathouse, Sift, or groir
back a minimum distance of 15' from my area of riparian access unless waived by
wish to waive the setback. you most initial the appropriate blank below)
Ntsl �4p I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement
(Property Own �OfF tali j
aee,n' -
Signaiurex4
A/
(Adjacent Property Owner
Signature
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Or>n1 nr Tu.�n Als..e

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© NC Division of Coastal Mgt. Habitat Impact COMF
Applicant: bw� l O �el�l�% w f 5 1
Date: 0 C� / m l
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.
FINAL Sq. Ft.
TOTAL Feet
FIh
(Applied for.
(Anticipated final
(Applied for.
(An
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
dist
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
rest
restoration or
and/or temp
restoration or
tern
temp impacts)
impact amount)
temp impacts)
am,
ow
Dredge ❑ Fill ❑ Both ❑ Other
Z
Z Z
Dredge ❑ Fill Both ❑ Other ❑
CIO
\to
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both 0 Other ❑

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to: `` j
A
A. Signature
Agent
X
2- ❑ Addressee
ecei ed Py (Punted Name) C. Date of Delivery
Ago
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: No