65181D - Dolan

TCAIVIA / ODREDGE & FILL 'NV, 6b
3,ENERAL PERMIT Previous permit #
New ElModification _jComplete Reissue —]Partial Reissue Date previous permit issued 01
Ized by the State of North Carolina, Department of Environment and Natural Resources n
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
t Name
State4g— zip
Fax #(—)
ed Agent J14001Y vfvAk
El CW 'r7 EW --' PTA -- ES El PTS
11 OEA E_'HHF — 1H Ll UBA El N/A
El PWS: El FQ
yes (,IV PNA yes ��; Crit.Halb. yes / no
Project/ Activity
*111eneth b'X IV/,
uesa c e
Project Location: County
Street Address/ State Road/ Lot #(s)
�'l 0111"
Subdivision
City zip 7 9
e
Phone # f.231— River Basin
Adj. Wtr. Body &of,& kow'%'/ ('n'at
Closest Maj. Wtr. Body
(Scale:
are
zr(s)
igth
nber
MEMO
M
ME
WON
Y Riprap length
-J MmIg:■�i::■■I�i:■i:
1
1100
PA
UF
N
ON
M
N■OMME
0
ONE
ONE
111111M
-nnel
■1001110111■NONE■EMENIIII
IN
0
E
JF
MEMO
-VAN-11111
�6�=961ww�r
mmm
F-P
'ft4
NEWS
40
=RA
ic yards
NO
FANVE
p
■
M
ON
Mm
M
owns
M
MEIN
0
---OEM
ONE
ow""WE
No■OMEN
M
EME■1110
MEN
rlrl�_
mm
(A
ME
InME
No
0
■■mms
11d0Z*
oe
No
mmo
wil
11
I
11
Ell
Is
IN
M
m
M
0
ME
M■!11110010
ONE
mom
f1110110
No
1IMMMMM
M
M
ENE
1111111110
M
1111111
��■■::11■::l.::::mom
111
not sure yes n 0
Emomm■mmomom
on
ENE
ONEEMEMI
�:w
IPM11mi
NEON■.
not sure yes n;)
ONNEMN■IN=
wool
Am: n/a yes nQP
::::yes
mm
W
E■
M
ON
O
no
Err:
N
IN
M
'tached: yes
M
g permit may be required by: 0 17 t YAA64011 , I) ❑ Senote on back regarding River Basin ru

Date Check I Check
Received Check From (Name) Name of Permit Holder Vendor Number amount I Permit NumbedC
4/9/2015 Coastal Marine Piers Bulkheads LLC Willard Buffkin & Kevin Dolan Wells Fargo Bank 200601 $400.00 JGP 65160D & GP i

Nt Division of Coastal Mgt. Habitat impact Computer Sheet
Npplicant: ��V/ DotG� @P"CT11t .0 ll��
Date: /I
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measuremen
`ound 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 firr
disturbance.
Excludes any
restoration and,
temp impact
amount
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 ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

�;.. "
Ar
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
'at McCrory Braxton C. Davis John E. Skvarla, III
Governor Director Secretary
AGENT AUTHORIZATION FORM
Date: A /,5// �
me of Property Owner Applying for Permit: Name of Authorized Agen rr this project:
ner's Mailing Address:
11 tr � ft M vro) .
P<9 i
,ne Number (-?0( 3G
Agent's Mailing Address:
Phone Number (9/0) ,,1 3 / —
lify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
ind obtaining all CAMA Permits necessary to install or construct the following (activity):
my property located at
certification is valid thru (date)
s_ J
Property Owner Signature Date

T-- — --
( ' //'
// ' '.~.~`

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to f� T/i/ 0 � 's
(Naive of Property Owner)
property located at 19 4-G anEJ ,
(Address, Lot, Block, Road etc.)
on "iygoco rp vN / z; , in tV2z n"
,E'er r 1 N.C.
(IWaterbody) «^n I (City/Town andlor County)
The applicant has described to me, as shown below, the development j,roposed at the above location.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
Ondh9dua/ proposing devefopment must iMT in desrnipbon below or aitx* a site drawing)
WAIVER SECTION
I understand that a pier„ dock, mooning pilings, breakwater, boathouse, tiffr or groin must be set back a
minimum dist my area of riparian access unless waived by me. (if you wish to waive
the setback, ou must initia he appropriate blank below.)
I do wish to waive the 15' setback requirement.
do not wish to waive the 15' setback
(Property Owner Information)
Signatuk Do L"*f
Print or Type Name
XI L,'q (f�on1 72
Mal iggAddress 28vd rr
(Ad' nt Property Owner Information)
Signature
i }4;2r'Lk : S�17 �- T- N
Print or Type Name
3/ L IQ C-1),,U �2
Mailing Address

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
i
I hereby certify that I own property adjacent to —�1 'A s
(Name of Property Owner)
property located at �� 4J&3ow � vzr
(Address, Lot, Block, Road, etc.)
on
(Waterbody)
in
(City/Town and/or County)
N.C.
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 goposing development must fill in description below or attach a site drawing)
A n/
x
WAIVER SECTION
9/
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.)
_P I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signa ure
Print or Type Name
g4' Z�16fo xJ 42
(Adjacent Property Owner Information)
��,.' -t; .
��Q—
Signature
Print or Type Name