64617D - Roeder

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CAMA / 1-1DREDGE& FILL
GENERAL PERMIT Previous permit#—
INew ❑Modification ❑Complete Reissue El 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 ©� n Rules attached.
t Name y
¢ i a� r� Project Location: County
}; Street Address/
,,Stat�Road/�4 t (s)
i1 S -S AAA
State ZIP �t A. f° V
� -! 1
t)q j Fax # Subdivision
t�j) (—) �
ed Agent %y e-W tJL....._ City ZIP
❑ CW P EW 'XffA C ES ❑ PTS Phone # ( ) Riv r Basin
❑ OEA 0 HHF t❑ IH ElUBA ❑ N/A Adj. Wt,. Body I iin:a
❑ PWS: ❑FC:
yes / no ; PNA es no Crit.Hab. yes no
Closest Maj. Wtr. Body
f Project/ Activity �� t �' e VV
ick) length�� L I
n(s) 1 o X 1S
�er(s)
:nth
imbe
id/ Ripra}p length
,g distance
ax distance C(fshore
:hannel
jbic yards_
imp
'use/ Boatlift
C
Bul
ine Length !�
not sure yes
igs: not sure yes
arium: n/a yes
yes
r Attached: yes
ding permit may be re
!j
(Scale:

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
D� (O I
Applicant:1)�li� �' Permit �#:
Date:
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 fina
disturbance.
Excludes any
restoration andh
temp impact
amount
(�
Dredge ❑ Fill ❑ Both ❑ OtherA
15b
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 [I Other ❑
Dredge ❑ Fill ❑ Both [] Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Applying for Permit
Mailing address:
IV6
Phone Number:
I certify that I have authorized ,
Agent / Contractor
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of 1L/ Z) D/'a do ' t l 5 IC6�JC
L)o--- 4=
at my property located at S^
in U lii )) O" County.
This certification is valid through
Date
(Property Owner Information)
//v
Signature
11�e-'
ZV
Print or Type Name
Title

ADJACENT -RIPARIAN PROPERTY OWNER STAIEMf,I[T
:ruw ty aciacent to
L2- le-4- ts
z(Name of Property Owrar)
#1
(Address. At -Block I Roadetc.)
cr it totsY1-Y . N.C.
ft%rbody) (CityfTown"and/or County)
Ott AFPk2ft 'Qs sesc->� *,-- Me, as shown below, the development proposed at the above location
X - I hWft'-'C Ctjecan to this Wti"a I .
-.1 - I how ccwec1*u,4 to tnis proposal
DitwisRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
110W --I, -, -fling development must fill In descriptlon below or attach a s1te drawing)
WAIVER SECTION
I underftnel 9W a Pier, dock, mooring pings, breakwater, boathouse, lift, or groin must be set back a
dstknm Of 16 from my area of riparian access unless waived by me. (if you wish to waive
twIllbscl YW nuAt inital the appropriate blank below.)
- I d* V*Ah to Waive the 15' setback requirement,
x I d0 1W Wish to,.va,,.,e the 15* setback requirement.
049PWV Oxmr twormation) (Adjacont PFOPIV OWIPW Information)
00-1
4Sign-q1tire
ZY400 Prot or rjip- �N&M*��
jj�!n

p,G,di,if
s

AUJAt, CIN I MII-AMIMN f-rNy 'CR i i VYYI`IGI\ J I f1I "IVIL.I• I
I hereby certify that I own property adjacent to C�c`A// leo 's
�i (Name of Property Owner)
property located at %�D v�J1��%' e �� �+.L VN
�/ f �e' (Address, 1-yt Block; Road etc.)
on I -Cin 7rtca�1 /=1�-Yy N.C.
(Waterbody) (City/Town andlor 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)
WAIVER SECTION
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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
r 1 ix Z/
ture
Print or Typ Nan
ftiting�ddr
City/ tatelzip �jp_
/U - 3..27- /OY/ f
(Adjacent Property Owner Information)
�A��4 zL(t9dd-
Signature o
TRoYKT"& onn
Print or Ty e Name
Owner ) +4 Old ins A)ne LarxJi yr
Mailing Address �ts �( o Snc�ls �vn{
City/State/Zip .
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