64678D - Sroka

�CAMA / - DREDGE & FILL a3 69
3ENERAL PERMIT Previous permit #
New —Modification EiComplete Reissue -Partial Reissue Date previous permit issued
sized by the State of North Carolina, Department of Environment and Natural Resources ))
Zoastal Resources Commission in an area of environmental concern pursuant to I SA NCAC T �21,(i
;K Rules attached.
It Nam Project Location: County✓VhS+�1C.L�-
1 CAk State NC ZIP �013
Fax # ()
:ed Agent CCBs4'6,141 a' -
❑ CW '0 EW I~},PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PPW-S:
yes /i no PNA
ElFC:
yes 6-0
f Project/ Activity F'l
, don,
ck) length
1(s)
ier(s)
ngth
mber
d/ Riprap length
distance offshore -
ix distance offshore
cannel
_.
Dic yards
np
ise/ Boatlift �� Z
ulldozing
e Length
JC)�
not sure yes no _
s: not syr, yes no
ium: n/a no`.
e;1 no
\ttached: ^yZ4;t
ig permit may be required by:
—lit
Crit.Hab. yes / no
Street Address/ State Road/ Lot #(s)_
1 ZL- - �A Al s � 1 >yI
Subdivis1ion
�ity - O - 12 e(t LL' ZIP ❑��i lC
ht ne '(1 (0 )Y
63 t335 River Basin 1A V11,
Adj. Wtr. Body CA.0 Cd na
r�1wvJ
Closest Maj. Wtr. Body
(Scale:
6w0 64 1cll',..T�1(C,L. _ ❑ See note on back regarding River Basin ri

M division of Coastal Mgt- Habitat impact Computer Sheet
,pplicant:
late:
S
Permit #: L -I L-4�
iescribe below the HABITAT disturbances for the application. All values should match the name, and units of measuremen'
)und in your Habitat code sheet.
labitat 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 Fmt
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated Tina
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 ❑
rc
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both. [] Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

MCDENR :
North Carolina Department of Environment and Natural Resou, Division at.Coastal Management
Beverly Eaves Perdue ,lames H. Dregson Dee Freeman
Governor Director Secretary
AGENT AUTHORIZATION FORM
Date: T O E 2 Zc� (,S"
Name of Property Owner Applying for Permit Name of Authorized Agent or this project:
1,15a W iclk _r-{y SO/v �.CJil1,S ry % o/J
Owner's MallingAddress:
'-�ay &— tZ 3F- IOP,
Q-
014 S�o r�•S� i1 �c�et� ��\j
Phone Numbera rg) 3(D`�- \I
Agent's Mailing Address:
ti c,{
Phone Number' )
i certify that 1 have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all GAiVIA Permits necessary to install or ,construct the following (activity):
(:
s�J�EKJY-
(my property located) at 12q 54 t—
This certifi ' n is valid thru (date) J
ma 621j
Property Owner Signature Date
RECEIVED
DCM WILMINGTON,

RIVAIUA-INt j-%Oj)jgZrnI, OWNER &XAT)DISL11
'dTj 'm
.(KO031ack)Road, etc,)
in AUr3
ApplIkant-la llme#
p
64 Lle. D, Q
niu-st �pc set bark -a jnir.,nju,,jj 4jgta,
_100 p , .
of lifteoll fea urrOL
Of'yolt Wish fo, waly'e the A. Oback "PAMM
4 You m a5f la iffi-11 tb
0
—1 dD W'Sb to WaivO that Wb=k
AINDIOR Djt_kjNqt, G Olp p'jtOpOS&j) I
bojille(ftit by qm
for A.Val
Addmss
f-,l)honliu

ADJACRa REPARWN PRO MTY 071MR STA.TEtY�`T
(FOSAPLDW' 0OYINGPTLItI?G+SBO,JTZIFW.a4=0WE)
I hereby certify that I own ptnpery acraaccut WITO
(t'�ame o . rogerty Otvncr)
property iocatcd at' �i
/ _ (Lot, Atx-kr, tRoad, etc) {�
on CAA lol in __ .f la c6p LzJ N.C.
CRaterbojjdy) 4 ' gorraand/orCounty)
_A.pp3zeantas phoneV; / ' / ` IY.ILugAddre=- �- ,
Ide has described to me, as shown below, the development he is proposing at flint location, and, I
have no objections to his proposal; I understand that a pietizoocing pillags I boatlift I boathouse
toast be set back a minimum dlstanae o Uten feet (IM Rom my area of riparian, access unless
waived bymc.(xfYou wish tbr"diyeYhe3cfi�ack,you=uAh4tW Ixe.wppropriate 6lauk
below.)
I do not wish to waive
I do wish to waive ihatsetback mquimment /, Olt C, C �yv
DESC�INTTXOANDIORDRAWING OFPROTOS i12 VT: �J—ICJ
(To be filledin by lhd duel proposing development)
6j-, , %itac)rl� �rrz wi Rq
Wormafion lorProperty Ow.nerApplying
for Permit)
5a.35 Soacy-m;t 6L
Mailing Addtew
(Riparian Pr-Qparty Omer Wormation)
FQc *
Mpawm
,-.�L,ppLl , �G ash_ iDaVid LEM1114.
i Print or Type Narne
3o-a�g�
e a Tm ephone Number
Signature Date Date

CANAL
<NORTH
17'10
_ .--- DCM WILMINGTON, NC
JUN 16 2015
16'
80 EXISTING
ZD
T EXISTING
12'
50'
Jerry Sroka
124Starfish Dr
3' 10
PROPC
15'