62593D - Belk

CCAI%AA'/ ❑ DREDGE & FILL
ENERAL PERMIT
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Previous permit#
New ❑Modification [-]Complete Reissue ❑Partial Reissue
Date previous permit issued
ed by the State of North Carolina, Department of Environment and Natural Resources
—4
� j�-1
oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
.
I INes
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attached.
Rul�f
t Name
Project Location.
County �/� j1
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Street Address/ State Road/ Lot #(s)
State ZIP 29
Fax # ( )
Subdivision
ed Agent YY1YYhI 'a on,
Ciry
Sl t °(l (,.(— ZIP
CW �EW '� PTA ❑ ES ❑ PTS
Phone # (%)
L5River Basin
1
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
Adj. Wtr. Bod
,, rr
(nat
❑ PWS: ❑FC:
yes / no PNA yes no Crit.Hab. yes Lno
Closest Maj. Wtr. Body AA W
A Project/ Activity
1 i)
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L L Vi i i *` ' i� t C V t' i 0 (A
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X `((Scale: I
ock) len f X' Lt
pier(s)
length
umber
ad/ Riprap length
vg distance offshore
iax distance offshore
:hannel
ubic yards
imp
ruse/ Boatlift
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X
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Michael F. Easley, .Governor Charles S_ Jon", Director
Authorized Agent Consent Agreement
Nifliam G. Rosa Jr , Secretary
is hereby authorized to act on my behalf
(Printed wane &Aoenr)
in order to obtain any 6AMA permits) requited for the property listed below- The authodzation is limited to the
specific :activities described ir, the attached sketch.
LOCATION OF PROJECT:
PROPERTY OWNER MAILING ADDRESS:
'i f Liz,
L NC, 2-7 9 PHONE NO. '7 Q 5 1
AUTHORIZED AGENT MAILING ADDRESS:
PHONE NO.
Signature of Property Owner:
Signature of Authorized Agen
[Sat

applicant:
V Permit #:
)ate: G�
iescribe below the HABITAT disturbances for'the application. All values should match the name, and units of measurement
)und in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
abitat Name
DISTURB TYPE Disturbance total
disturbance.
Disturbance
disturbance.
Choose One includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts)
amount
V
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other
---- -
. ,,. 1
-11 L, -11Gl "
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 ❑

DIVISION OF COASTAL M. ANAGE.\1ENT
\DJACENT RIPARIAN PROPERTY OW?NER NOTIFICATIONIWAIVER FORM
Name of Individual Applying For Permit: _I��rzn Be I k
Address of Property: � 1 12 V e 0 17
(Lot or Street #, Street or Road)
(City and County)
I hereby certify that I own property adjacent to the above -referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development they
are proposing. A description or drawing, with dimensions, should be provided with this letter.
I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coastal
Management, 127 Cardinal Drive Extension, Wilmington, NC 28405 or call 910-395-3900
within 10 days of receipt of this notice. No response is considered the same as no objection if
you have been notified by Certified Mail.
WAIVER SECTIOti
I understand that a pier, dock, mooring pilings, breakwater, boat house or boat lift must be set
bek 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 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
Sign Name Date
Print Namer ;
7 J ' 7 7 / '" � ate• / .�.�.���.�.
Telephone Number with area Code NCDENR
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CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
,
Name of Property Owner:
Address of Property: ' CY f kit �n " rI 4 O' ( 6 EAU f1SW-64 )
(Lot or Street #, Street or Road, City & County)
Applicant's phone #: �I V Ui 1 0 ✓ Mailing Address:
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this permit
has described to me as shown on the attached drawing the development they are proposing. A description of drawing,
with dimensions, must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM)
in writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext
Wilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift 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 do wish to waive the 15' set back requirement.
I do not wish to waive the 15' set back requirement.
(Property Owner Information)
Si nature
01-is Wr�
Print or Type Name
I �40-L Aav&n 4,
MAling Address
(Riparian Property Owner Information)
�OA
Mailing Address

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