69177D - Waters

ICAMA / ] DREDGE & FILL ' 1l,-7
A B
;ENERAL PERMIT Previous permit#
lNew El Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
•ized by the State of North Carolina, Department of Environment and Natural Resources 67 �/
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC (j ❑ Rul attached.
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t Name 'O E Project Location: County ��/u l
L% 7Z At S Ad Street Address/ State Road/ L t #(s)
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Mail ��''�,� , `I s7 4
:ed Agent
❑ CW EW �T'TA ❑ ES ❑ PTS
❑ OEA ❑ HHF / ❑ IH ❑ UBA ❑ N/A
❑ PWS:
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f Project/ Activity
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Platform(s)
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Adj. Wtr. Body W� at
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis
Governor Director
AGENT AUTHORIZATION FORM
Date: 5 ( (— R -
Jame of Property Owner Applying for Permit:
— r-Y 4 —
)wner's Mailing Address:
_4Jr&*,5
!l1-! a3
'hone Number (910) 2i3 - ® Sao
John E. Skvarla, I
Secretary
Name of Authorized Agent for
this project:
� ire l�1 �r �rll1
Agent's Mailing Address:
q$d 4,V rec/3 1U.
Phone Number LO
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
Dr and obtaining all CAMA Permits necessary
or my property located at
'his certification is valid thru (date)
install or construct the following (activity):
Mr
Property Ow er Si nature
� �&tiK P
Date

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Own
Address of Property:
Agent's Name #:
Agent's phone #:
(Lot or Street #, Street or Road, City & Cou
Mailing Address:
I hereby certify that I own property adiacent to the above referenced property. The individua!
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing with dimensions must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
if you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no objection if you have been notified by Certified Mail
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.
(Pertyner Information)
Signatur
Print or Type Name
Mailinn Arlrinocc
(Adjacent Property Owner Information)
_
a
Signature
U' "ws �
ntor Type Name
AA�;G— A r -'-

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to _eR�;_. �• j J a
)
property located at (Name of Property Owner)
y76 /�(d/'p,�,da � �
(Address, Lot, Block, Ro d, etc.)
on xC< G✓ in y N.0
(Waterbody) City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above Ic
Vw
_ F I have no objection to this proposal.
I have objections to this proposal.
ut5CRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must till in description below or a ch a site draw
4,vir d#4 A' rLvldce �pi/,�,� Ot-t neeied �$ _a „d k
ail 410dilin �c do /l�� e"k 'r
V
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 tc
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 Property Owner Information)
Sign ture Signature
Print yperName A( Print of Type NA
me /I iv

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NC Division of Coastal Mgt. Habitat Impact Comps
i�
Applicant:/� ow e W"
Date: S , 3D
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
FIN,
(Applied for.
(Anticipated final
(Applied for.
(Anti
DISTURB TYPE
Disturbance total
includes any
disturbance.
Excludes any
Disturbance
total includes
dish
Exd
Habitat Name
Choose One
anticipated
restoration
any anticipated
rests
restoration or
and/or temp
restoration or
teml
temp impacts
im ad amount
temp impacts)
amc
Dredge ❑ Fill ❑ Both ❑ Oth
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other 0