69164D - Williams

CAMA / El DREDGE & FILL 1 a. ,0 A B
MN ERAL PERMIT Previous permit #
t4ew ❑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 I SA NCAC � 4,D Rules attached.
Name lo, V`V\ lM ' ��4t Project Location: County �y i _seti► K
�(4S-f p(. Street Address/ State Road/ Lot #(s)
►� �AVA 7[VA W Mate_ L ZIP
(7 Oi" (, o6f - $�I b Ei'I^"FaiI Subdivision n —r-
ed Agent OtVr, }4-JVIV< a C �Wa61C kAWV'T— [C�itY �+^ 1jf�C1��i t Get` ZIP 1
❑ Cyy A ❑ ES ElPTS I'hon� (� a) "� " t - { Ri er Basin V Wh
[IOEA ❑ HHF IH El USA ❑ N/A Adj. Wtr. Body C ktn L�, (nat
❑ PWS:
Closest Maj. Wtr. Body l WIA J
yes / r 6--) PNA yes / fo)
:ngth
be
d/ Riprap I gth
g distant// offshore
ax distapce offshore
yards
mp
use/ atli
1
3ulldozing
ne Length _J V
not sure yes CO)
mum: n/a yes
yes
Attached: es no
ling permit may be required by:.
t1.
ME
(Scale: , it -
See note on back regarding River Basin

■ Complete items 1, 2, and 3.
10 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:
ya-,44-,v�P-15 kOTO�
A.
Agent
❑ Addressee
(Printed Name) I C. Date of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
t
3. Service Type
❑ Priority Mail Express®
II
I'll
II
I'I
II
I II
i III
I I
i IIIII
I II III
❑Adult Signature
El Registered Ma IT"
II Il
II III
❑ Adult Signature Restricted Delivery
❑ Registered Mail Restricted
9590 9402 2021 6123 2956 01
ertified Mail®
Certified Mail Restricted Delivery
Delivery
❑ Return Receipt for
❑ Collect on Delivery
Merchandise
-'- "�• • tie. rr —fpr from service label)
❑ Collect on Delivery Restricted Delivery ❑ Signature ConflrmationT
.16 0 910 11002 1223 0989
1:1 Insured Mail
❑ Insured Mail Restricted Delivery
11 Signature Confirmation
Restricted Delivery
(over $500)
PS Form 3811, July 2015 PSN 7530-02-000-9053
. Domestic Return Receipt

JC Division of Coastal Mgt, Habitat Impact Computer Sheet
,pplicant: tl&vv j t Permit #.
)ate: 6f /C, / -o( -7
)escribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
ound in your Habitat code sheet.
iabitat Name
DISTURB TYPE
Choose One
Dredge ❑ Fill ❑ Both ❑ Other
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
andfortemp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
UAJ
t
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both El Other ❑
Dredge ❑ Fill 0 Both ❑ Other ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION.
n r
Name of Property Owner Applying for Permit.
Mailing address:
Phone Number: � 01 Z
I certify that I have authorized
16?1Ve /-&/� '5'
Agent / Contractor
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
�
necessary for the proposed development of 1 �("� °t
.. n f,
at my property located at
in 'oVil /S'AUt�--k County.
This certification is valid through �'—/��/ %
Date
(Property Owner Information)
I
Signature
Print or Type Name
�A-k2�
Title

_.._..... ---...............
Lkiit'1'IFIED M' --R. MEN RR IP - --
,, STED
T
DIVISION OF COASTAL MANAGFJ ENT
ADJACENT RXPAR AIN PROPERTX• QWW STATIZMEN-T
Name of Property Owner.
Address of Property I i 3r,4
(Lot or Street #, Street or Road, City & County) "
A,pplicanes phone #:_ �j2- 6 Mailing Address:
I h*Mby eertfy that l own property adjacent to the above referenced
has described to me as shown on the afttacb� drawingthe individual applying for this pe;
with dimensions. the development they are AroposM& description of draw
ril!>�.�� v�'dtd...with tfiis l�
1
i,`L�� . I have no objections to this proloesaL I have objections to this proposal.
rf you have objections to who is being propOSed, you mast notify the Division of Coasted Mal=
In writing within 10 hays of receipt of this notice, Core- gernent (D0
espondence Should be ensiled to 127 Cardiaai Drive l
W'Iee$ngtDn, NC 28405-384& DCM representatives can also be contacted at (919) 796-77
considered th Na rgsponsc is
ume as no obeectoon i# se have bee uo " ed Certified L
WAIyFA SECTION
I wukrstand that a pier, dock, mooring pilings, breakwater, boathouses or lift must be set back a minimum distance
15' from my arts of riparian access unless waived by me. (If you wish to waive the setback, you most initial the appropriate blank below.)
I do wish to waive the 15' set back mquitemeut.
r�
I do not wish to waive the 15, sec back requirement.
(Property Owner Wo manation)
Sipature
Print or Type Name
luMailiag Address
City / State / Zip
Telephone Number
Date
(Riparla» Property Owner Iaforraation)
)(Signature
Print or Type Name
Meii�g Address
CA 5 S a— txloqA
City / State / Zip
Telephone Number
Date - c?/ ) c! / 7.01-1

03-16-' 17 13:33 FROM -
RECEIVED 03/16/2017 12:31PM
T-153 P0003/0003 F-062
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