67994D - Wright

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.,NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: 3 v(/� (N AA,
Date: 6 Z �0
Permit #: (e � affi - (�
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
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
Dredge ❑ Fill ❑ Both ❑ Other
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 ❑
Dredge ❑. Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge [❑ Fill ❑ Both ❑ Other ❑ .
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both Q Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

ime)
of
Number
amount
%
Number/
Refund/Reallocated
Permit
Comments
Holder
John M.
BB&T
1861
$200.00
GP
SF 3493D
istruction,
Wright
67994D

NCDETVR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
terty Eaves Perdue Braxton C. Davis
vernor Director
AGENT AUTHORIZATION FORM
e of Property Owner Applying for Permit:
L�� _ _ --
J
er's Mailing Address:
i
Dee Freemar
Secretan
Name of Authorized Agent for this project:
Agent's Mailing Address:
s_H5= H5 Construction, LLC
_ MT"ffm 2798 Sea Vista Dr.
Supply, NC 28462
e Number t1.51 —? yo G Phone Number 111 0) gSS o — 4 3 mid
ify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
id obtaining all CAMA Permits necessary to install or construct the following (activity):
ny property located at ��S! j AL — !
certification is vafi thru (date) N 1.4A)
441 _..Q
Signature Da#

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to _ �1 arl �' { ` �r`'� - s
(Name of Property Owner
property located at ` t � � L Jc > it e �-i<� ;fir j,�r �� PLL� G
C' (Address, Lot, Block, Road, et6�,
on ��IAGLti�7ta r`.y%�� in s%�,,, K Ihl4 <,^,�A)r) 1; t�f N.C.
(Waterbody) (City/Town and/or 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 objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in description below or attach a site drawing)
tgo
6i ,
WAIVER SECTION
i understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse. lift, or groir
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.
(Property Owner l�rmation)
"Signature
Print or Type Name
(Adjacent Property Owner Information)
siggff1ture
Print or Type Name,

MLJJMLGI� I r%1rhRI1A11 rRVrG/R l i VYYPICR '0 1 M i r-mr-n 1
I hereby certify that I own property adjacent to ri. �,�. rr ii l s
A _ —. „ 1 In. . _. (Name of Property Owner)
property located at
,,. tAoaress,
on L.,,'t e , tl in
(Waterbody)
(City/Town and/or 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 objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
I
i
btl��. \�
I
a
WAIVER SECTION
�)6l'4
I understand that a pier, dock, mooring pilings, boat ramp, 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 the appropriate blank below.)
I do wish to waive the i5' setback requirement.
do not wish to waive the 15' setback requirement.
roperty wner Information) (Adjacent Property Owner Information)
, atum Sigmaturn*
Print or Type Name �— Print or Type Name
Mailing Address Mailing Address
S'4S1L i, � AEC x .�' %C1 Re, <. It' ii. � C A 9 % 1-�.-
City/State/Zip / City,I&atel&