63110D - Pelican

IdAMA / _ `DREDGE & FILL
"3ENERAL PERMIT
New Modification ❑Complete Reissue -Partial Reissue
Iff
�` 63
Previous permit # 4-+---
Date previous permit issued ---E
rized by the State of North Carolina, Department of Environment and Natural Resources L
;oastal Resources Commission in an area of environmental concern Pursuant to 15A NCAC
A ! l ElRulesrttached.
t Name �� i E-t�.M �Oclr ll �ick Project Location: County p E,M �! ��..
©✓P 5o 4/11 Street Address/ State Ra Lot #(s)
StateN4C—" ZIP Z-7 U ✓ J Q��—• L Gt�f��C....-
1-205 ' Fax # () Subdivisi n
ed Agent 127 10,41f //!1C ' 6-,t)VS 7. � City A vl t ZIP
❑ CW EW PTA ES ❑ PTS Phone # ( ) River Basin
❑ OEA
❑ PWS:
yes nd
❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ FC: _
PNA yes / no
Project/ Activity
k) length ❑
igth
nber
i/ Riprap length_
distance offshore
x distance offshore
annel I--
sic yards
1p
;e/ Boat
e Length
-r .- Zoo --.
not sure yes
not sure yes
um: n/a yes
yes
,ttached: yes Ue!"=
ig permit may be required by:
Crit.H/ab. yes no
al
d / v'S --
Adj. Wtr. Body A l yZ)k.) (nat N
Closest Maj. Wtr. Body f� /t 5 6/
V
(Scale: / I'.
❑ See note on back regarding River Basin ri

WESTERN( (MONEY
WESTERN UNION FINANCIAL SERVI E1NEnglewood,ISSUER
UNIONORDER Peyable Wells Fargo Bank Grand Junction -Downtown, N.A., Orend Jun=lion io 2 0 518 2 8
14
A 3,41149 D 022514
^24L 82 tit; L 181
145_
PAY EXACTLY TWO HUNDRED DOLLARS AND NO CENTS PAYMENT FOR/ACCT. #
PAY TO THE
ORDER OF _
PURCHASER'S ADDRESS gCMRSER'SSGNPTURE
> 7
1.L ;I?P05L8280+�°

PPlicant: Pa4c4lq Soado
ate: L —1+ C/� 14-
-CA I -ti A/ Permit #:
ascribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
DISTURB TYPEtotal
Name Choose Oneny
. Ft.
or.
d
Til
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 final
disturbance.bitat
Excludes any
restoration and/or
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Othe
alp
/3�ji s"
Dredge ❑ Fill Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
❑ Fill ❑ Both ❑ Other ❑
:::Dredge
DredgEFi11❑ 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 ❑
�L�

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date 2—Zf-1YJ�I
Name of Property Owner Applying for Permit:
P11-/� tg �,,v .►.r �/"f
Mailing Address:
Y
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)
at (my property located at)
This certification is valid thru (date)�—
v
Property CKvder Signature
R
Date

--jr%%. iztr i rxir,Km1AN MUF'LKTY OWNER STATEMENT
I hereby certify that I own property adjacent to s
(Name of Property Owner)
property located at (� f / tC1 i1 ��'� ; � �l°
��`� (Address, Lot, Block, Road, etc.)
on in ./w, C! �fr% N.C.
(Waterbody) — (City/Town and/or County)
i
The applicant h escribed to me, as shown below, the development proposed at the aoovE;
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)
!� 6 (,)Cl Cr �� D O n
�� a oUo vo CU 0o
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be se:
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.)
Zldo wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
Signature 60 Tnn
ature
Print or Type Name z Tye Names L' t'r
� CC��// � � � �
Maili g Address a $ M �t ng Addres
IQ C-
City State2ip City/State/Ztp
co - -q ( - ao ��

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to
( / (Name of Property Owner)
property located at
(Address, Lot, Block, Road, etc.)
on fL l:, in o Cr 41 , N.C.
(Waterbody) ( ity/Town and/or County)
The applicant has described to me. as shown below, the development proposed at the aoov,
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)
U0115 prod 0 0 o'. D C�
t 060 00 06 UC' > p c�
667e
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 dQ-wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Sii�nalure
print or Tvpe Name
(Adjacen Property Owner nformation)
�44
Signature
L.
Print or Tvpe Npme �� l

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