62597D - Cauthern

CAMA / DREDGE & FILL
33ENERAL 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 `) I I oO
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC 1
2ZRules attached.
it Name A' ty" Project Location: County i�riJ1'1S
Street Address/ State Road/ Lot #(s
G., u state NT ZIP 1 bS i ✓i 0 / b u
(. Fax # ( y
zed Agent u
a
❑CW EW PTA XES ;7APTS
❑ OEA HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑F
ye / no PNA yes no Crit.Hab. yes �'/ no
3f Project/ Activity i
lock) length
m(s)
pier(s)
length
umber
:ad/ Riprap length
vg distance offshore_
iax distance offshore
channel
ubic yards_
imp
Ouse/ Boatlift
Bulldozing
DWvkil!5Cb A
►2a'�x�
ne Length
not sure
yes
gs: not sure
yes
wium: n/a
yes,
yes,
Attached:
yes
ling permit may be re
/ Snecial C^nnelitinn
Subdivision. N
city )1 4ti I-'D4f1A U., ZIP 2S4
Phone # i) � 434 91 ` River Basin
Adj. Wtr. Body W W (nat
Closest Maj. Wtr. Body
(i
(Scale: 1 �1

kpplicant:
v Y�— Permit #: � L% _ sc�
)ate:
escribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
fund in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft. TOTAL Feet FINAL Feet
(Applied for.
(Anticipated final (Applied for. (Anticipated final
ibitat 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,im acts)
impact amount) temp impacts) amount)
IDredge ❑ Fill
1 zo
Both ❑ Other
Fill Both ❑ Other ❑Fill
❑ Both ❑ Othe
ill ❑ Both ❑ Other ❑ill
E
❑ 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 ❑

7013 0 1 : 4 8
#6557 P.002/t
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PXE.RINOORING PH-TN'GS1Zl0e4 TI.IFT1B0ATi10 US1E)
] hereby certify that 1 own property adjacent to--'s
(Namv�vf Owner)
s Gt
property located at c�w�C �-- ' J V N� h✓•• . �•',, a (,`
(Lot, Block, Road, etc.)
is 1. /�.+ x. E��, .�_ , N. C,
(Waterbody) (Town and/or County)
Applicaut's phone #:. ��'iViailiug Address: r
He has described to me, as shown below, the development he i$ proposing at that location, and, I
have no objections to his proposal. i understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
i do wish to waive that setback requirement. - ` ___
AESCRIpTION AND/OR DRAWING Op PROPOSf)l7 ULVELOPMENT
(To be - filled in by individual proposhig development)
((Information for Property owner Applying
for Permit)
L�
Mailing A441ress
Z-0 y 4
Citylstawzip
'X clephone Number
(Riparian Property Owner Iniartnataou)
signature
-6CLS��13-rtllt OT Type l+lamG
Teiephone Number

ANO ,"�r�`
L.4197
IV, ?VP
r b 1 P4.
oaj —
�agoCWe_7
Y7

r
North Carolina Department of Environment and Natural Resources
Division of Coastal anagement
Beverly Eaves Perdue James H. Gregson Dee Freeman
Governor Director Maly
AGENT AUTHORIZATION FORM
Date: 7- 7o--Za/'3
Name of Property Owner Applying for Permit: Name of f A nz�gent for this project
Owner's AWiling Address: Agent's NaNing Address:
/UZvS t'4".WAI rz� 19�' /-`�� �.0
N6 Z! �e/ I
I .R 9"V�- Z
Phone Number (704 7�� --I 4 d � yip Phone Number ( 1 g113-I/
I certify that I have authorised the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
,C J 14 A
(my property located) at , % �i 7` "' �r •�- f 1« •e,� /U
This certification is valid thru (date)
Property Owner Signature date
127 CaAW orne EA
Phom-. 910--M72151 FAX 910,V&M We"*: www ga *nwananl.fce1 `turally
AA Eq" OppnMAy\ AS—W ACko Fiidu�a