64603D - Nethertron

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�CAMA / ❑ DREDGE & FILL 1 / �J
GENERAL
PERMIT Previous permit#
ew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
>rized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
` , +i � � t` � Rules attached.
it Name f�:►R N t�v tolz V 5 t tni ��SS^(. Project Location: County �`(U1�Stit1
61 utgba b L AV Q Street Address/ State Road/ /Lot #(s) `
I LI&ym (-K State\ffiZIP
( � -U t) Fax # ( ) Subdi ision N
zed Agent City
i ❑ CW 'XgW ,LSIPTA C ES ❑ PTS Phone # ( ) Vn�D�� t River Basin _ rV
❑ El OEA HHF IH ❑ UBA N/A Adj. Wtr. Body C �l (nat I
❑ PWS: ❑ FC:
yes ), 11 no PNA yes(/ no ) Crit.Hab. yes((no
if Project/ Activity
3ck)
:ngth
ember
id/ Riprap length
,g distance offshc
ax distance offsh
:hannel
ibic yards_
mp
use/ Boatlift
ie Length'
not sure yes
gs: not sure yes
rium: n/a yes
� Oyes
Attached: yes
Closest Maj. Wtr. Body Af lAJ
(Scale:
ing permit may be required by:--TU)8 L� ) (Al F,,)eA.LA, ❑ See note on back regarding River Basin

w ilZino
aial 10
MIIIaO mantle wnuauui a, �Lv
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An Bray
First Bank
First Citizens Bank
Citizens Bank
First Citizens Bank
NC State Employees' Credit Union
GP 64619D I
Mary Ann Tally
5/1/2015 5/8/15 Land Management Group, Inc Orton Plantation holdings, Allen's Creek Bridges
5/6/2015 5/8/15 Eastern Builders Inc Thompson
5/6/2015 5/8/15 Eastern Builders Inc Thompson —First
5/1/2015 Bald Head Island Ltd. same
5/7/2015 Don B. or Connie C. Jordan same
5/8/2015 Wayne Smith & Son, Inc Joe Smith
5/8/2015 Ricky Hewett construction Ruth Netherton & Vicki Jesse
GP 64620D I
major fee, Br
minor fee, W
minor fee, N"
mod fee, 19f
j GP for Jorda
iGP 65138D
45408 $250.00
3322 $100.00
3323 $100.0f)
1511 $100.00
2806 $200.00
19291 $400.00
4488 $200.00
BB &T
BB &T
GP 64603D
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'NC Division of Coastal Mgt. Habitat Im act Computer Sheet
Applicant:
Permit #: f (62
Date:
lU �10
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measuremen
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)
I FINAL Feet
(Anticipated fins
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 ElFill [IBoth ❑ Other 1-1Dredge
❑ Fill ❑ Both ❑ Other ❑

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
AGENT AUTHORIZATION FORM
)ate: <{ /2 Z/ 1 t�-
Vame of Property Owner Applying for Permit:
RU-t 4 �S-n4 PIC—VCXAVkG I RV-:7-t
Mailing Address:
t ce (2f WET-bIZvv K Ave
Dee Free
SecrE
T!-I 64A AA- ts, ►> � VGA ti � 7r7�7
Phone Number: A04)
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) O `x �,C' 4--(,-oA "G-yUy--t MCA. w4
at (my property located at)
This certification is valid thru (date) �.ykt PL6 t�QE "1?=LJ5::'-�T
A-W U3
.,-4/--,7_Zile

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
jtu T to J . T9VS11
I hereby certify that I own property adjacent toCKi L. J ii�5,56t"s
(Name of Property Owner) ��c
property located at i �� pr 5 pp
T (Address, Lot, Block, Road, etc.)
on 4 �-7i, LL i�� i4A?-0tZ (AM U in ticL. © 6 N i� N , 1`lC— N.C.
(Waterbody) (City/Town and/or County)
The applicant h s described to me, as shown below, the development proposed at the above locatioi
✓ I have no objection to this proposal.
have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must rill in description below or attach a site drawing)
To I U' FAM P t�j la'xt2' �FUOATt ne,- VC&e,
W I T4+ N t=W t U' A M P
WAIVER SECTION
understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wai,
the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
JA4L ---- I do not wish to waive the 15' setback requirement.
- 141 lAIZ F1�5t-1 Vj:�;
(Prop _ y Owner Information) (Adjacent Pro rty Owner Information)
Signature - Signature
y[ t�V—i V . ,jr�f lT���7r1✓� ��dc�(� ��I-rririnIrc�
Print or Type Name Print or Ty a Name
t(62i WX -? T ��)OI� Ave ci 11 L�4A�11a r � t r

Page I of I
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINOA�FTBOA SE} _
Zvi J. g F&Y -{Rus r)
I hereby certify that I own property adjacent to f&QN jlN 11 's
(Name of Property Owner
property located at �Tft�F.15W Did
(Lot, Block, Road, etc.)
one E2�tZi:lDR �IAG,inO( 47lrN 2 (oZN.C.
(Waterbody) (Town and/or County)
Applicant's phone #: "' 4bS- (<ii4)Mailing Addmss:lS�_l 1�sr 1�sTt���ar� � 4 Ve
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 pierfrnooring pilings / boatlift / boathouse
must beset back a minimum distance of fifteen feet (1 S') from my area of riparian access unless
waived by me. (If you wish to waive the setback, you mast initial the appropriate blank
below,)
N/A I do not wish to waive
tV I do wish to waive that setback requirement
----_.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be f filed in by individual proposing development)
-Co RC-PbX.C-e C-XthTIN4 I U' -RAMP Al 5'4 1 2! FWATOAc-
DO&W— w I T" Kr— 10 1(0' RAAP ' 6 x 14' "F WAT I Me;
v0e-K
-----------------------------------------------------------
(taformation for Property Owner Applying (R
for Permit) %.
Rl CLAAA421s112, VA Z57Z Z
City/State/Zip
PnA-_ fit'? S - to l -A D
TelvhoneAu� Aber
Signature Date
i Property Owner Iuformation
S A �i✓ l S E i71Z.11IrVT�F�
Signature
14 , o .-3v,
Print or tvoe Name
L4 o 4- 2?-? - F, o I (o
Telep one Number
I
Date

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