61508D - Formyduvall

L ICAMA / El DREDGE & FILL
GENERAL PERMIT Previous permit#
ZNew -'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 � H . ( �. Cjc,
Rules attached.
nt Name K, f -H 1, fVWV L'1 U V k I Project Location: County L Y L)o
s UZI a' INC
' b'+l�M'Ci+C StateNt
ZIP" 4RO _
#( 55e17? Fax#( )
!zed Agent�,ta G n (l U !'- +
d ❑ CW O EW V!, PTA ❑ ES
ElPTS
❑ OEA ❑ HHF ❑ IH ❑ UBA
❑ N/A
❑ PWS: ❑ FC:
Street Address/ State Road/ Lot #(s)
Subdivision
City 6k r ZIP .5 iItk
Phone # (91 )943 ` U9 River Basin —Urn
Adj. Wtr. Body (� t CIF �1y4 (n t
14-
yes / no PNA yes / ao Crit.Hab. yes / no
Closest Maj. Wtr. Body I ��
A Project/ Activity P 1 6 I �, i 4-1
(Scale:
ock) lengffi . ✓i v Y. G
m(s) � L X y
length
umber
ad/ Riprap length
vg distance offshore
iax distance offshore
channel
ubic yards
imp
)use/ Boatlift
Bulldozing
ne Length
not sure
yes
no ,
/no \
gs: not sure
yes
)rium: n/1
yes
no
yes
.
Fnr:
Attached:
yes
ling permit may be required by- {{ 1 OWO b�' V1(A (' � t� ❑ See note on back regarding River Basin
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
AGENT AUTHORIZATION FORM
late: 1 ` 9 -13
lame of Property Owner Applying for Permit:
�c�v Fgcmm akfcL(l -
failing Address:
� Z CC010aS �Oad
S lea (I Ott -
hone Number: (9 10)
Dee Fre
Sec
certify that I have authorized (agent) gVg11 �z ope r to act on my
ehalf, for the purpose of applying for and obtaining all CAMA Permits necessary to install or
Instruct (activity)
t (my property located at) g3Z CopaS qc S Lce l lol e- , NC -
his certification is valid thru (date)
-.,a -Of-� � - 12 -a .

e_- C.JC,t I vc.`+r
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGS((BOATLIFTBOATIIOUSE)
I hereby certify that I own property adjacent to Re- (' M a U Va I l is
of Owner
� P tY )
property located at S �;-)—
(Lot, Block, Road, etc.)
onSVla 16AC— Q%ve- ,in5kct a-q-e 46�UJ'SLJ;(-k Co, ,N.C.
(W erbody) (Town and/or County)
Applicant's phone Mailing Address: 83 Z
e, C, ;L%o
He has described to me, as shown below, the development he is 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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
q3-2- & N-s i`.oa j
Mailing Address
(Riparian Property Owner Information)
Signature

e 1b</1 vG,/
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIEAIMOORING PILINGSBOATLIFTBOATHOIISE)
I hereby certify that I own property adjacent to e r,�- rov I u U a I I is
(Na ie of Pro erty Owner)
property located at gJ3Z Co p a S
(Lot, Block, Road, etc.)
onSL�1� DCU1SW�C�. ,N.C.Jt�,��
(Waterbody) (Town and/or County) f7
Applicant's phone Mailing Address: 932- CD9a5 %�l•
.;�a1l6�e. NL 2g4 `70
He has described to me, as shown below, the development he is 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 (1T) 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)
(Information for Property Owner Applying
for Permit)
S32 was ",
Mailing Address
(Riparian Property Owner Information)
i/ Signature
. i . . I.. )

I ..
1pplicant: I�YY1 AV YA l I
Permit #:
)ate:
lescribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
)und in your Habitat code sheet.
abitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
6 W
Dredge El Fill ❑ Both El Other
�q�
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 ❑
X to = 1 �30 0

RYAN D. COOPER
NCDL 8375610
PH. 910-443-4829
P.O. BOX 1393
SHALLOTTE, NC 28459
PAY TO / V C,,D—E---M
State Em loyees' Credit Union®
-P ��j//t Supply, NorthCarolina
66-7704/2Ml 1111
DATE 2 + — / 3
$ 20v ov