63173D - Neely

3 ,
�*ICAMA / C DREDGE & FILL
GENERAL PERMIT Previous permit# N /a
XNew LLModification LJComplete Reissue El 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
❑ Rules attached.
it Name K NE& t,u Project Location: County _PF—Na--zrz—
o Pc?X 3 c:-;,-j(o 1 Street Address/ State Road/ Lot #(s)
❑Q P Sk I C >Pt State'J C.- ZIP Z q;q I 1 r3 (,o -q
/o ) 328_Q8iS` Fax # ( ) Subdivision
ted Agent &-' A NOS/ CS A//u t S City A1-" i— -57T^ D ZIP Zk
❑ CW CHEW ,PTA DES ❑ PTS
❑OEA ❑HHF ON ❑UBA El N/A
❑ PWS: ❑ FC:
es no PNA yes / no Crit.Hab. yes / no
f Project/ Activity
'y
>ck) length
n(s)
)ier(s)
angth
amber
prap length ,-o
JI
g distance offshoreT
ax distance offshore /
hannel `^"�-•--.ti
bic yards
np
ise/ Boatlift
,ulldozing
Phone # ( /o )rj' yt0 --5/3S River Basin %Z„
Adj. Wtr. Body / e- -57c,11 A.1D Oft
Closest Maj. Wtr. Body 70P5�t S
Emommommol'oommmmi
EMENEE ONEEN oil
EMEMEN MENNEN I
FMANEIIIIIII
V (scale: / "z
❑ See note on back regarding River Basin r

INTERNATIONAL MONEY ORDER 75-53
919
MoneyGram.
10-0
To Validate: Touch the top sign,
s then watch it fade and reappear
PAY TO THE
ORDER OF:/
cD PAGAR A LA
ORDEN DE:
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_IMPORTANT - SEE BACK BEFORE CASIUN
x x +:
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PURCHASER, SIGNER FOR DRAWER COMPRADOR, FIRMA DEL LISRADOR
C) PURCHASER, BY SIGNING YOU ACRES TO THE SERVICE CHARGE AND OTHER TERMS ON THE REVERSE SIDE
ADDRESS:/ ®r
DIRECC16N
Payable Through ISSUER/DRAWER:
Wells Fargo Bank, N.A.
Faribault, MN MONEYGRAM PAYMENT SYSTEMS, INC
1:09111900S31311:S90
977OC3448110
01
90 6e 65RAD
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INTERNATIONAL MONEY ORDER
MoneyGram.
To Validate: Touch the stop sign
then Watch it fade and reappear
:-0— ......... . ..
PAY TO THE
ORDER 0
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W11"121 X*,`::�`
PAGAR A -,T1 ., . , !. I
SIMON.;
ORDEN DE -
IMPORTANT - SEE RACK BEFORE CASHING x
00111 "m 01 111 Will AP
PURCHASER, SIGNER FOR DRAWER / COMPRADOR, FIRMA DEL LIBRADOR
I( PURCHASER, BY SIGNING YOU AGREE TO THE SERVICE CHARGE AND OTHER TERMS ON THE REVERSE SIDE
ADDRESS:/ /M fl
DIREccibN'. v 3/ 4-4111 P/
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Payable Through ISSUERIDRAWER:
Wells FanoBank, Wk. .7 j:.: j
Faribau It N MONEYGRAM PAYMENT SYSTEMS, INC.
75-53
919

pplicant: 77-7 �A ►� A (�L, Permit#:
ate: y D
^ ' V �J
ascribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
bitat Name DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impact)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
im act amount)
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)
Dredge ❑ Fill ❑ Both ❑ Other
lDredge ❑ Fill Both ❑ Other ❑
O
O
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 ❑

' DiACENT RIPARIAN PROPERTY OWNER STATEMENT
herebv certify that I own property adjacent to
(Name of Property Owner)
property locatee
(Address, Lot, Block, Road, etc.)
on 7-Cw1.J Olh& Q) /.v7g- in I-Jg v�, n,, 4-ed.
(Waterbody) (City/Town and/or County)
The applicant has described to me. as shown below. the aevelopment pr000sea at the aoov�
iocauot
i have no objection to this proposa,
nave objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
.Individual proposing development must fill in description below or attach a site drawing)
P °P<<�
W �Y
60t �J�r � x 157,
WAIVER SECTIOt
i understand that a pier, dock, mooring pilings. breakwater. boathouse. at. or aroin must ne sz
back a minimum distance of 15' from my area of riparian access unless waived by me. (it VOL
ish 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.
(Prope Owner Informa . n)
Signature
t%
,;n nr TvDe Name
A/.'O /A._i — _--7 .
(Adjacent Property Owner Information)
,/ CIYyj
gnature
S AW V, 7iV& V )svN
Pnt or Type Name
A h -� I "- ... / 's '/ A..►. .. , "e � \

_DJACENT RIPARIAN PROPERTY OWNER STATEMEN
I hereby certify that I own property adjacent to ��'�: vl (� At e l" s
(Name of Property Ownert
property iocateu c, z X 11 / dr U � d
(Ad ress, Lot, Bloc , Road, etc.)
on J CwL) ( 01CAe m'd'Sle4d v.�.
(Waterbody) (City/Town and/or County)
I he applicant has described to me. as shown below, the development proposed at the aoovc
iocatio;
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)
,o
�sei
i J)
jOrOp�SPI
WA!VFR 4RFrT1n1E
I understand that a pier, dock, mooring pilings, breakwater. boathouse. lift, or groin must De s:
back a minimum distance of 15' from my area of riparian access unless waived by me. di you
—is
h to waiye the setback. you must initial the appropriate blank below.)
f1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement
;Property Owner Informat
Signature
k VV ;A('2
,int or Tvpe Name
A.\"
(Adjacent Property Owner Information)
),-A "
Sign ure
St-41(ZO N M SN ITZ) of
Print or Type Name
J< .-0 .i/nIG cq..nrT,All- Pit

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date �3 Z— 2�
Name of Property Owner Applying for Permit:
Mailing Address:
7
1)
I certify that I have authorized (agent) r/ © to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) �Ul �/` TY Z
at (my property located at) 4 � ( l � :�, 14
This certification is valid thru (date) 2 -� --/,
Property Owner Sip -nature
Date