69179D - Wooten

,CAMA / DREDGE &FILL A B
aENERAL PERMIT Previous permit #
New '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 15A NCAC
ules attached.
t Name / !�L/4O'��� Project Location: County(O
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i State Nc-ZIP S
Street Address/ St t Road/,,Lot #(s)
E-Mail Subdivision
ed Agent 06 e., � `e/ &Xt, City / 4aW ZIP_Z<-Z/'
❑ CW 1f7fEW *TA ❑ ES ❑ PTS Phone # (------"" River Basin
❑ OEA 'ff HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body 4000J, at
❑ PWS:
yes � PNA yes
Closest Maj. Wtr. BZd�Y!1-4'- +
Project/ Activity (V5(4 0
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ng permit may be required by: ❑ See note on back regarding River Basin r
Local Planning Jurisdiction)

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■ Complete items 1, 2, and 3.
Si ture
■ Print your name and address on the reverse
so that we can return the card to you.
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■ Attach this card to the back of the mallpiece,
p
Received b y (P ' t a
-
Addressee
) C. Date of Delivery
or on the front if space permits.
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I. Article Addressed to:
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D. Is delivery address di fare
If YES, enter delivery dress
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erti ied Mail®
❑ Certified Mail Restricted Delivery
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❑ Return Receipt for
Z. Article Number (Transfer from service /abe/)
❑ Collect on Delivery Merchandise
❑ Collect on Delivery Restricted Delivery ❑ Signature ConfimtationTM
7 015 1730 0002 1686 8175
insured Mail
nsured Mail Restricted Delivery
❑ Signature Confirmation
Restricted Delivery
PS Form 3811, July 2015 PSN 7530-02-000-9053
over$500
Domestic Return Receipt

NC Division of Coastal Mgt. Habitat Impact Computer St
1plicant:DaA Wncf,e� r
te: 5' , 2.0 • ( --�L 1
scribe below the HABITAT disturbances for the application.
values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated fina
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
ibitat Name
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts
amount)
Z'
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 ❑

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date _ s�/fla 7
Name of Property Owner Applying for Permit:
Mailing Address:
In
I certify that I have authorized (agent) to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at)
This certification is valid thru (date) S/,�e/�

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to L_ I rt� f (Jr64,&" __ is
(Name of Property Owner)
property located at C Md ,
(Lot, Block, Road, etc.)
on IAA , in 71 6 t4-Zi , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: D 3 Z t Mailing Address: Z F:6� q
ti q 5
He has described to me, as shown below, the development he is proposing at that location, and,
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
I do wish to waive that setback requirement.
-----------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
--------------------------------------------------------
(Information for Property Owner Applying
for Permit)
Mailing Address
(Riparian Property Owner Information)
� r
Signa

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBbal
OATLIFTIBOATHOUSE)
I hereby certify that I own property adjacent to wDofe-q is
/ a (Name of Property Owner)
property located at �© `7 6 C �a,4 n Fj U ly�lo
(Lot, Block, Road, etc.)
on (d il5rxr SfJcJ , in nASa<r( 6e , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: 0 3 & 7 a(6-5 Mailing Address: i 2- I%Lrolk Gf .
A/a f�, /Vc- 2844E
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
I do wish to waive that setback requirement.
-------------------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
/80.s� ma f� ��•
Mailing Address
(Riparian Property Owner Information)
Signature

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGS/BOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to I & ( (-,417-Vr, 's
(Name of Property Owner)
property located at i CJ 3 Z
(Lot, Block, Road, etc.)
r--
on
in / �Y9 , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: 2/19 A 7 IQ 15 9 Mailing Address: � 2—, -r- -f
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
I do wish to waive that setback requirement.
---------- - ----------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT: --------
(To be filled in by individual proposing development)
-----------------------------
(Information for Property Owner Applying
for Permit)
--------------------------
(Ri avian Property Owner Information)
Mailing Address

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