63152D - Clark

�CAMA / r DREDGE & FILL
GENERAL PERMIT Previous permit* N
$CNew Modification Complete Reissue ❑Partial Reissue Date previous permit issued N
orized 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 d� ht i2oc�
❑ Rules attached.
,nt Name 6 4 �J GI.,A P_ K Project Location: County wefl--
N TO hl State N C.. ZIP ? 3 --I
#fL(Z)591� --4�� i Fax # (_ )
ized Agent h� /)d---
d ❑ CW `4 EW PTA I—, ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑ FC:
yes / no PNA yes /0 Crit.Hab. yes / no
Street Address/ State Road/ Lot #(s)
It 14 C m4g-� (�
Subdivision
City JUS&I L. P?CNA ZIPS
Phone # ( ) / e River Basin CFJ
Adj. Wtr. Body TO F,;^ j L I,)
Closest Maj. Wtr. Body TbL4SCK) 11J)
A Project/ Activity I W-, A t I � LU E' i i N6— DfX_it_
(Scale: ) "
ock) length
m(s)
pier(s)
length
umber
ad/ Riprap length
vg distance offshore
iax distance offshore
:hannel
jbic yards
imp
'use/ Boatlift
3ulldozing
T wO01-IIE'a - 6,)(
ne Length
y
not sure yeses
gs: not sure yes
rium: n/a yes
yes G.
Attached: yes, no
ling permit may be required by: —VW4^ 1 l _ PtZ r i ❑ See note on back regarding River Basin

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SAMPSON
BLADEN
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John .Claris
Vice President
�0�000
P.O. Box 469
Clinton, NC 28329
Mobile [phone]
:irk C7vsampsonbladen.com Office [phone]
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pplicant (�
ate: Z Z'
Permit #: 6 % 15 .Z
ascribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
TOTAL Sq. Ft.
(Applied for.
bitat Name DISTURB TYPE Disturbance total
Choose One includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
im act amoun
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
ODredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
nQD
Dredge ❑ Fill ❑ Both ❑ Other ❑
b
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill El Both El Other El
Dredge El 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 ❑

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
____ (Name of Pro a -- Owner
property located -at----- --- - -- --- --- --- P rtY . --�-------
(Address, Lot, Block, Road, etc.)
(Waterbody) ' (City/Town and/or County)
— The-applicant--has-describes - o-me-as-shown-belowl the -development -proposed -at the-above-locat
I have no objection to this proposal.
I have objections to this proposal.
Ut:bUKIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing,
WAIVER SECTION
1 understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bac
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wa
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.
irroperty Uwner Information)
Signature
Print or Type Name
(Adjacent Property Owner Information)
Signat _
Print or Type Name ,

------property-locateZJ
ody)
Owner
k"?A Ulva.
(Address, Lo�_Block,
(City/Town and/or County)
-- —Thep"licanf=has-describes- o-me—as-s own -below; the -development -proposed -at the -above locat
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
1 understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set bac
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to wz
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.
(crop ny Owner Infor ation)
/ I /'� �'
rgnatu
�'Ar
T
(Adjacent Property Owner Information)
Si to L
Prim or Type Name
Print or,,Tybe Name

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