62639D - Faulk

CAM,A / /DREDGE & FILL ✓ lr� 61
P' E N E RAL PERMIT Previous permit #
New ❑Modification _ Complete Reissue ❑Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources
oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
❑ R s attached.
Name ie Project Location: County 6P_ S O
MStreet Address/ State Road/ Lot #(s)
State ZIP
(_t ) a,!�Z Fax#( )
ed Agent
CW EW PTA ES ❑ PTS
OEA HHF IH UBA ❑ N/A
C PWs: ❑FC:
yes / no PNA yes f'iio) Crit.Hab. yes
Project/ Activity
ock) length
m(s)
pier(s)
length
umber
:a�)Riprap length
vg distance offshore__
iax distance offshore
channel
ubic yards
imp
fuse/ Boatlift
Bulldozing
ne Length
not sure yes
gs: not sure yes
)rium: n/a yes
yes
Attached: yes Gi
ling permit may be recli
r/ 1A
Subdivision
City 5 L c/ ZIP
Phone 4� 0 &f.7 - / River Basin _
Adj. Wtr. Body<? A�� arr > C feat
Closest Maj. Wtr. Body
(Scale:

pplicant:' cc:r?-Q r �� .V .( f
ate:
Permit#: t 2_6 3q
=scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB
TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
ibitat Name
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)
�47
Dredge ❑
f> Both ❑
Other ❑
d
Dredge ❑
Fill Both El
Other ❑
Dredge ❑
Fill El
Both [I
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 ❑_

...............
GEORGE E. FAULK
PH. 919-934-3060
PO BOX 1197
SMITHFIELD, NC 27577
DATE
L L A R S
nk
le
;883110 1:0531003001:00324971297911n
Rim
66-30/531
324

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to L=-ev r i G �-� ��4 �A' s
l (Na om Pr pe O ner)
property located at y �' J � /
r---,p
(Address, 1-91, Bloc, �pad a c.)
on � C; (I/ Jy in C. N.C.
(Waterbody) (City/To n and/or County)
The applicant has described to me, as shown below, the development proposed at the above locat
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 descriptionlbelow or attac a site drawini
y�
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set b
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.
(Propertg Owner Information) (Adjacegt'property Oyvner Information)
or Typb Name Print or Type Nam@
,,1 L1_4, cam-„

AMA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis
Governor Director
AGENT AUTHORIZATION FORM
Date:
Na roperty Owl App i n g f.ermit:
Owner's Mailing Address:
k
John E. Skvana !II
Secretary
Name Authorized Agent for this project:
Agent's Mailing Address:
Phone Number ( S� i 24>2 — 32-Z3 - Phone Number " l�) 3d4
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 necessary to install or construct the following (activity):
For my property located at
This certifi tion is valid thru (date)
Property Owner Signature Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ('� ec, r � e z- /a-'k �9� s
ame�f Property Owner)
property located at
(Address, Lou Blo
on L !yL , in.
(Waterbody)
etc.)
(City/T6wn'and/or County)
N.C.
The applicant has described to me, as shown below, the development proposed at the above locatic
i' I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOqED DEVELOPMENT
(Individual proposing development must fill in description elow or attach a site drawing
Y '7
4p-t-7 /
le-
:3-q '
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set ba
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to V�
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)
i
Si tune
Print or Type Name
(Adjacent Property Owner Information)
lv� -112 Lezz
Sig ature
,/\ Vg,2 V //J/
Print or Type Name