61663D - Attoe

eAMA / ❑DREDGE &FILL
,/' M 61
GENERAL PERMIT
Previous permit #
New ❑Modification ❑Complete Reissue El Partial Reissue
Date previous permit issued n
>rized by the State of North Carolina, Department of Environment and
Natural Resources L f
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
.--�
it Name �:/� f t�
❑ Rules attached.
-V
Project Location: County "E >�-
t� Np Vl y✓
Street Address/ State Road/ Lot #(s)
State ZIP
Fax ## (_)
Subdivision Al.,f
zed Agent: t/.14�;6-'
City i� 1• G ZIP
i ❑ CW ❑-EW ❑ PTA ❑ ES ❑ PTS
Phone # ( ) River Basin
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
Adj. Wtr. Body�;
❑ PWS: ❑FC:
yes / no PNA yes / no Crit.Hab. yes /q
Closest Maj. Wtr. Body basil /L
if Project/ Activity
1)&' / 'z N
ock) length
m(s)
pier(s)
ength
umber
ad/ Riprap length
ig distance offshore_
iax distance offshore
:hannel
ibic yards
MP
use/ Boatlift
Bulldozing
ne Length t
not sure yes
gs: not sure yes
mum: n/a yes
yes
Attached: yes
ling permit may be r
(Scale: J r:

r. � � _ .e-y. I ..-.���,2 let.• )plicant. Permit #: J r�
ate:
( G 13
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
ind in your Habitat code sheet.
TOTAL Sq. Ft.
(Applied for.
)itat 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
impact 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)
. )
vv Dredge ❑ Fill ❑ Both ❑ Other 6
v
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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

742
15-3/540
690
Date
a,TfJ
$ a�
it Dollars
220L2S13 2

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue Braxton C. Davis
3ovemor Director
Dee Free
Secrf
AGENT AUTHORIZATION FORM
Date: %1/ G 13
ame of Property Ojj'ner Applying for Permit: Name of Authorized Agent for this project:171)
Nner's Mailing Address:
lone Number (Sin) 7%Z-z 2 o — --;Z G r�
Agent's Mailing Address:
3504 7-4L(-
I—) - t.-„ la ru � , ,v e
Phone Number (9,"D 3 86
ertify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Permits necessary to install or construct the following (activity):
it my property located at 1 �"-�a�-��I /�- �� '�'�`'� r'� c
v �
is certification is valid thru (date)
c%-/(.-/.3
perty Owner Signature Date

1
REPLACE �
L--s-
P.EPIACE7 4x 24�
W.4LKWhy4- 3'x 12,
ZrFF ATT'OE"
WILLM/►� LONG glg S4uNb/1Eye/
822-50UNbVIEh/ J%R
---SOUND-Vewo
OSCAR WEST
$1(o SOUN6VIEW AR

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to L �P, 4 �T �� 's
ame of operty Owner)
property located at ( �%� S n r f �; '—; vL
(Address, Lot, Block, R ad, etc.)
on Yh. /� C p.L in , N.C.
(Waterbody) (Ci /Tow and/or County)
1 he applicant has described to me, as shown below, the development proposed at the above loc
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 drawl
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to
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)
Sign e
Print or Tyke Name
(Adjacent Property Owner Information)
Signature
Prinkor Type Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Je tt //
(Name of Property Owner)
property located at
on j%],�/l (Address, Lot, Bloc , Road, etc.)
injz r zre N.0
(Waterbody) (CityIT wn and/or County)
T he applicant has described to me, as shown below, the development proposed at the above Ic
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 draw
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish tc
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) (Adjacen Pro rty Owner Information)
Signa Sign
Print or Type Name t or Type Name ,ov