62564D - Davis

❑CAMA /-iDREDGE & FILL
GENERAL PERMIT
Previous permit #
�lew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
orized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
❑ Rules attached.
.-
nt Name ivi E a A \i
Project Location: County C 'xJ i'E / --
s
Street Address/ State Road/ Lot #(s) p ek
1Rl I' State . State�j�ZIPZHI
�GY . L_> i ca✓ 14 . S/o
l _ 7-6 Fax # ( )
Subdivision e1"'c
ized Agent ( ) h3
City hYtA Pj� ZIP
El❑ CW (� EW _; PTA ES ❑ PTS
Phone #) 1 —' Z 03 q River Basin
d
❑ OEA ❑ HHF _ IH = UBA ❑ N/A
Adj. Wtr. Body A 1 VV (/J (na
❑ PWS: ❑ FC:
es J no PNA yes / no Crit.Hab. yes / no
Closest Maj. Wtr. Body ��!�%u
A Project/ Activity i ,'�/} 54 !t
(Scale: 1
ock)leneth
pier(s)
length
umber
ad/ Riprap length
vg distance offshore_
iax distance offshore
-hannel
ubic yards
imp
it i 3 z
Bulldozing
ne Length -
ji
not sure
yes
gs: not sure
yes
>rium: n/a
yes
yes
Attached:
yes
ling permit may be required by: -�C' U See note on back regarding River Basin
P

pplicant J Me S
ate:
Permit #:
,scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
bitat Name DISTURB TYPE
Choose One
TOTAL Sq. Ft. FINAL Sq. Ft. TOTAL Feet FINAL Feet
(Applied for. (Anticipated final (Applied for. (Anticipated final
Disturbance total disturbance. Disturbance disturbance.
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) im act amount) temp impacts) amount)
C"v Dredge ❑ Fill ❑ Both ❑ Other,
14
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 ❑

;ONSTRUCTION, LLC
3OX 11291
ON, NC 28404
Fargo Bank, N.A.
mWells
North Carolina
wellstargo.com
66-21/530 10141
D 2801 10 1:0 5 3000 2 L 91: 5 5 1,08 681B01,11'
7/23/2013
$ **200.00
i�•
DOLLARS
AUTHORIZED SIGNAT qE

f�dg SGo1ff //'( `/ Loar
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER4I00RIVG PILI-NGSBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to �"�.L��r r1��lie 1-901� f
�(dame of Property Owner)
property located at 660e l < LOv�O Aa f
-z$�ock, oad, etc.
on , in D i1 , T
(Waterbody) (Town and/or County)
He has described to me, as shown below, the development he is proposing at that location, and, I ha,
no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse must be
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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
It you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Est. Wilmington
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
(Information for Property Owner/Applicant
Applying for permit)
1r'D /,?& x /1.2-V1
Mailing Address
(Riparian Property Owner Information)
Signal
G�i'`lRs ,rI AAIS

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date 3
Name of Property Owner Applying for Permit:
ft 5 V. DA✓rS
Mailing Address:
I Ell k i ✓6 OA- )< L A�JC-
W -t ( wt I N a -T2� ,c1 L/( a 8 4-/ /
I certify that I have authorized (agent) '�'ZN to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) Xr) 'L 4
at (my property located at)n� j, � Cyr � �� `���n
f ���r �;rt,�A
This certification is valid thru (date) z�,
15_`t:$'

/' R/y ///f r ylr`
56,0h,s /% / Le o/ W.
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/YIOORLVG PILI_VGSBOATLIFTIBOATHOUSE)
I hereby certify that I own property adjacent to d1,,,4^ �/`(/e �/n t
/)(,Name of Property Owner)
property located at
U
�� , � (Lot; k, ad, etcLegal
)
on !'Y , in ,r
(Waterbody) (Town and/or C unty)
He has described to me, as shown below, the development he is proposing at that location, and, I ha`
no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse must be;
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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext. Wilmington
DCM representatives can also be contacted at [phone].
No response is considered the same as no obiection if you have been notified by Certified Mail
(Information for Property Owner/Applicant
Applying for permit)
l /uk /��w
Maa`i�ling Address �%
//n t ilk /l�/U /' - � -" ,;zgj
I--.1C'-_ 117'
(Riparian Property Owner Information)

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