66226D - Fullerton

JCAMA / ❑ DREDGE & FILL
1� ,1A
GN ERAL PERMIT - Previous permit #
Alew []Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
prized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
Im Rules attached.
nt Name l,._. 4r l4 ���✓ Yr Project Location: County ZVZ—h - 126-4rZLZ- --
s 2 17r( Street Address/ State Road/ Lot #(s)
�AlJ<I, �rStateZI P 2 /� Z j %�� /�iG•r
Subdivision
zed Ageenn �7" 1 /'!C f l jfy� City �l Al, %ui�l�'i
ecw Mi/OIG ❑ ES ❑ PTS Phone # (f -Ve/r/River Basi ,r i'
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ WA ! h !!�c
Adj. Wtr. B i h nat
.,o oil.;.,5; aNe f /
,l �„ Closest Maj. Wtr. Body
if Project/ Activity
g Platform )
ength
umber
ad/ Riprap length
✓g distance offshc
rax distance offsh
=hannel /
ne Length
not sure yes ©°
wium: n/a yes
ano
Attached: yes
ling permit may be required by:
e Local Planning jurisdiction) —I
❑ See note on back regarding River Basin

,om (Name) Name of Permit Holder
Vendor
Number I
amount
Permit Number/Comments
Refund/Reallocated
Carl Fullerton
First Citizens Bank
2187
$200.00
GP 68226D
RM rct 1393D

NC Division of Coastal Mgt. Habitat impact Computer Sheet
Applicant: tt
Permit #: 2 z G
Date: I Z' 15115
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
LN u
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)._amount
FINAL Feet
(Anticipated fina
disturbance.
Excludes any
restoration and/
temp impact
C V v
Dredge ❑ Fill ❑ Both ❑ Other
Vv
Dredge ❑ Fill ❑ Both ❑ Other EY
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
AD
NCMIR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis John E. Skvada, III
Governor Director Secreta,y
AGENT AUTHORIZATION FORM
Date:
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
L,.Q.L, z` 10� kOQfit a���tK ro.�i
�ATzRt�r� s^'t-
Owner's AfAai/ing Address:
Q7 IS Z n I d C AG.. Le
Val, L, n. , ry (, t Crr4 t-,) L
Phone Number (aa01) `f f'j S II I
Agent's Uailfng Address:
F3 I'7 �c2t,.zu N R
�J r `rh n t7rJ1 N C,
agyo9
Phone Number (9 1 Q) ).6 k '3 r.Y4
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all LAMA Permits necessary to install or cormbimt the following (activity):
r c R O C V— 1Ja L .i
T
For my Property Located at 87 a6 a n L1) L A it L E
This certification is valid thru (date)
Property Owner nature Date
L,
RECEIVED
DCM WILMINGTON, N(
D E C 15 2015
127 CaidvW ame EA., ftrinom NC 2W

�...� t3C li r�Gl
ADJACENT RIPARIAN PROPERTY OVMER STAT NO& I.
MORAPIER/MOORINGPHXVCx BOATLIFTIROATHOUSM
I hereby certify that I own property adjacent m L NQ. L-
(blame of Property Owner)
PMpeM a. 81 � A L-t & A U L. C h N
(I^ Mod4 Road, ere.)
on t v—i (,, W C- Q ZF- iC , in NG L,-) N A t� Dom) �-,. 2, , &C.
(Waterbody) Clown and/or County)
Applicant's phone#' 11Q-a61-364q Mailing A&wess; 81 "l DE2t/�iy N ►k j
sie has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I tmder*wd that a piedmoodng pilings / boa= / boatinne
rarst be set back a minumrm disw= of fibm fax ( l 5� from my area of riparian access unless
waived by me. (If you wish to waive the setback, you must initial the appropriateblank
Wow.)
f do not wish to waive
I do wish to waive dW seft& tegraenu t_ N/A
DESCRIPTION ANIVOR DRAWING OF PROPOSE DBVEiAPMEN'i:
(To be filled is by individual proposing &Pdopmarl)
(Information for Property Owner Applyug
for Permit)
B1�,S �n�17 &AbLC -rj
W,L,m )N (+-'T'ON t,.) L
City/sweLip
Teiechone Number
ao i - `i 1-7 S ), 9 7
(R4arian/PProperty Owner
Signaumz
(c ZAJ
Q p/ Print or Type Name
//Ao7�-

11
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t
RECEIVED
DCM WILMINGTON, NC
DEC 1 5 2015

ADJACENT RIPARIAN PROPERTY OWNER STATENS i
(FOR A PTPH/lKOORING PZUNGSBOATUPTIBOATHOUSM
I hereby certify that I own property adjacent to (- AQ tL-
(Name of Property Owner)
prop" X a< H� a� A Lt�. & A (r- L t h N
(Lot, Block, Road, etC
on a c, IA c- 0.cE e , in Nc 1,.� !) a N n.) 2 , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #:91 D-a 6�-36y Adorers- H 1-lGC
�i�t.Mrnlf.) ON N L 9W 9
rie has described to me, as shown below, the development he is proposing at brat location, and, I
have no objections to his proposal. I understand that a pia/tnooring pilings / boathi t / boatitottso
must be set bade a minimum distance of fifteen feet (15) from my area of riparian access unless
waived by mr- (If you wish to waive the setback, you must initial the appropriate blank
below.)
t do not wish to waive
I do wish to waive that sefck tom. N/A
DFSCREMON AND/OR D"VMG OF PROPOS19D DEVV OPMBN'::
(To be filled in by &44dud propostag &velopmPni)
S 2, t AvAuN tom.
(Information for Property Owner Applying (Riparian Property Owner Information)
far Yan-taitl
a1�S 3n��
lrlallft Address USignature
�,m.lYr Iry �'�oN N t,[CE�✓,G,.
City/StateJLip Print or Type Name
Teietabone Number
ao1- Hrl S197
'/ o -��C> c /j-d
Telephorx NtRnoe:
/ 5
qionantra-

mat--
0
CEO
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3
Jf
R;c-7CE!VEL-
)CM WILMINGTON
nnic

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e
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4f h�
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RECEIVED
DCM WILMINGTQN, t
DEC 1 5 2015
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