62544D - Black

CAMA / JCREDGE & FILL
GENERAL PERMIT Previous permit #
New ❑Modification - Complete Reissue [-]Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources -! r
j
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC J`" 1
DRG es attached.
nt Name -&-hy4e 1?it e fK -7Tj `(/ Project Location: County
CIC 10NJ -S F3
s - �TW=j i l } Street Address/ State Road/ Lot #(s) Lc"F Z
"1Y State N („ ZIP Q: l k Qr J
#( Fax # O Subdivision
ized Agent (, GT"V `�� I1)( a4 ✓ ;�:-", iJ City ;(.' d<� i � ZIP A.
d CW EW PTA
OEA HHF IH
u PWS: FC:
yes / no PNA yes / no
Df Project/ Activity
lock) length (r "• k
piers) ? 7 7
length
camber -
.ad/ Riprap length r
vg distance offshore
nax distance offshore
channel
ubic yards_
amp
)use/ Boatlift `
Bulldozing
ES PTS Phone # ( ) River Basin c
uBA N/A Adj. Wtr. Body na
Crit.Hab. yes / no
Closest Maj. Wtr. Body
g
ine Length '2 ii1c %
not sure yes (no
igs: not sure yes (no
)rium: n/a yes iho
yes no
Attached: yes /,-no y max
ling permit may be required by: /
(Scale: ' f/ :
❑ See note on back regarding River Basin

e �
Applicant: jl �(,� 2�11(�iL {�'� Q Ic �(1QP��� Permit #: J_
Date: +�/' Z� (3 �(.J
)escribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
ound 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
tern impacts)
impact amount)
tern impacts)
amount)
Dredge ❑ Fill ❑ Both ❑ Other GK
I L[l
Dredge ❑ Fill ❑ Both ❑ Other Lam,
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 ❑

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Cash,er's Check_
- 9
_ ._- -- -
BrancllNo -
—__- _ _-- - ----
66-30/531
08536696
July 02, 2013
--
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ust Company
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$200.00
;OAgTAL MANAGEMENT
V4
FIRST --
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xiwners
n loss. uns Inced or Stolen
or an In ur m Brind may he w9uired before an officialvt�4
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04FCM011556
3669'112 i:053 L003001:980 L99499011'

AN
NCDEENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis John E. Skvarla, III
Governor Director Secretary
AGENT AUTHORIZATION FORM
Date: 7 1
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
1Z1�iyt✓1� ft19#Yi C Prop02-r7�es TC F -V
LL-Cl-
Owner's Mailin Address: Agent's Mailing Address:
/ 2Z3 iV -
s- -Sot Al Gi
Phone Number 3 6 67 s—i 1 7 Phone Number( C) C>
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits nece � sary to install or construct the following (active :
S � r wadu a3 �a-Vs
FT)( Wser,: e-4 `t q y v /,-�? / o"/ ,
For my property located at LP f 2 rt
This certification is valid thru (date)
Property O r Signature
21
�3
Date
IRr7CEIVED
DAM WILMINGTON, NC

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to (�IrG��t i ��r 6-f �/ C- ! L-L
(Name of Property Owner)
property located at L04 t f L- ottly ( 04-r V-e�
on C� G �- (ddress, Lot Block, RoV-
(Waterbody) tc.)
(,�- in 2�C n ' N.C.
(Cityrown and/or County) 67
The applicant has described to me, as shown below, the development proposed at the above 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)
Maf ailaap�
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.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
Zignatre eature7n"
on ` G4 e, 6 1.( �a �� er6A it f-h i fio c- Pop e- �e s
Pnnt or T N me P' f T
-7y� p �,�tlti?.�z
nn or a Nam
iMQa�ilin Address � / e M, a- if ing Address
1;, . . 1„ �a Iy-�— �/`� i ►1 S d7r� ; ^ S Cy� piiy� �i L 7 %

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I hereby certify that I own property adjacent to gI'GGk R Iye, /� S` 0f-1 e- 1 /b 4-ass L
property located at l:0 tL,n f p ei nerl
on _ � j �,,- (Address, Lot, Block, Roa , etc.)
in r e P� Cd .71
C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above 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)
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 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)% (Adjacent Property O er Information)
egnature Signature
n� GLC 1 �i /. 1� 16{G�C V Cyr 6� lwSi C e�"�'` i
Print or Tv a Name Print or Type aC%lwt'l' A0, 3yso k�e
Sye,/iifv Cha AoeLd
Ml�jno %l -cJA leAl N C- 9--)7 t n�airinq adorqss ,, r 771