69079D - Topsail

CAMA / DREDGE & FILL
3"ENERAL PERMIT Previous permit#
New Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources ( ,
Zoastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
n 6ve
/J❑Rules attached.
it Name owo cl T C : 4/ Project Location: County
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Comments
4/3/2017
First
Town of Topsail Citizens
Beach same Bank 6118 $200.00 GP 69079D

NC IDIVISIOn'Of CO St�l "gt. Habitat 1rnp�lct computer �Poe�t
� w 01
Applicant:
/
Date: 3
Describe below the HABITAT disturbances for the application.
in
Habitat code
sheet.
All values should match the name, and uniis of measurement found your
FINAL Sq• TOTAI Feet
FIN,
TOTAL Sq. Ft.
(Applied for.
(Anticipated final
A lied for.
Dist ance
(Ant
dish
DISTURB TYPE Disturbance total
includes any
disturbance.
Excludes any
total includes.
any anticipated
Excl
rest
Habitat Name Choose One anticipated
restoration
and/or temp
restoration or
tem
restoration or
ternim acts
im act amount
temp ini acts
amc
�v
W Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill El. Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑. Fill ❑ Both ❑ Other ❑
" Dredge ❑ Fill ❑ Both ❑ Other ❑'

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: —F of BPS A%t C
Mailing Address: Su"'J .
�PSA� L 3�f�c \A NL a� �) y
Phone Number: ��'( t C`-I
Email Address: `T'c \.N-> ,-3 iN,c F 0 -tL)Ps A,IL91eNC i\ . C')2 (A
I certify that I have authorized ,SEryt.��IFF 0-- jZ'E N4-1J ,
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: +r' \t-)6-C-(Z 5
r�L� AT T�ys E4 j\n, Z
at my property located at 9 la
in �County.
1 furthermore certify that l am authorized to giant, 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.
Pr party Owner Information:
^� Signature
i"�cNF� L �I�osc
Print or Type Name
Title RECEIVED

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to 'SCJ-51" _pit A i AL 14 T �t 6's
(Name of Property Owner)
property located at S A"�:,E p Uc ,I p
(Address, Lot, Block, Road, etc.)
on Nk S. C� 4 t,., C in "TUPSpN , N.C.
(Waterbody) (City/Town and/or County)
T e p c t 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 AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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 you 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.
( r perty Owner Information) (A ja ent Proper Owner Inf rmation)
Si iatrrre Si Mtn e �,
Print or Type Name Pri o'Name
Mailing Address_ _ Mailing Address , i

ADJACENT RIPARIAN PROPERTY OINNER STATEMENT L S U G- (JC-N1t
I hereby certify that I own property adjacent to 9t LA MC +Q L- � 's
(Name of Property Owner)
property located at r q I Lei oice (p .
(Address, Lot, Block, Road, etc.)
on `j3p,r.�`� S �� apt")" E 1<._ , In _ `Tc� P s��L F C kC- kA N.C.
(Waterbody) (City/Town andlor 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 ob)ectlons to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill In description below or attach a site draivind)
WAIVER SECTION
I understand thal a pier, dock, mooring pilings, 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 you wish to waive
the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback reslulrement.,
_ I do not wish to waive the 16' setback requirement.
(P o arty wner Informatlo��) (Adjacent P rty Owner Information)
Sign Nara .51galf
Print or Typo Name Print or Typa Name
Mailing Address Mallin Addro s
-r-r,ncaji 2 cry-r a nN1 ��,r. I/Y , /9 All,

Boat Slip Diagram
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