62629D - Gross

,. CAMA / ❑ DREDGE & 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
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
75pules attached.
nt Name � .� ( as's Project Location: County j �/ �;1 "1 Sl -4 1 0'
J t X1rl _ State ZIP V
ized Agent 'l AAA
d ❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF X1H ❑ UBA El N/A
Street Address/ State Road/ Lot #(s)
'&S , Subdivision /A
A "_ LUwt I�L(� �A (� ZIP
Phone # ( )423 — River Basin 1U ol
❑ PWS: ❑FC: Adj. Wtr. Body Q iC Urif C11.n. nat
yes/ no PNA yes no 1 Crit.Hab. yes tlno Closest Maj. Wtr. Body Aire-kj L �yCL
A Project/ Activity j V1S 17(U Ai V 4 UV 'YZI YIA 1 A SU K L
(Scale: ,
ock) length
length
�■■■ yi'1
�i■■F� .:1�11■ ir.►,;l1►+ice
vg distance offshore I
■O■ , . ■ ■ ■■6IL+11111N_
e ZRAW97-9010 IN
channel
■■■■■■■■■ ■■
■■■■■■■■■
ubic yards
imp AMM
■■■■■r_■■ ■���
)use/ Boatlift
Bulldozing
x
ne Length -0
not sure yes no
gs: not sure yes no
>rium: n/a yes no
yes no
Attached: yes
ling permit may be required by: I `� A R El See note on back regarding River Basin
i s---:_� �__�:�:--- —� U I 4TA A a !' A L( AU 1 ./ I k-, I ri i, i e i._ i � i..f . - t i _� 1 L

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: (c" C C'j �� Permit #:
Date:
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measuremer
found in your Habitat code sheet.
Habitat 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 fin,
disturbance.
Excludes any
restoration ands
temp impact
amount)
Dredge ❑ Fill ❑ Both Other WWa�
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 ❑

1007
G 8 9i430
141
�a,<
i
-- ] $ qw,. cam.
«,
Dollars "
bci"' on
ECI b
zi mo + ZA AV
I1?1252261I' 1007

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis John E. Skvada, Ili
Governor Dim tary
AGENT AUTHORIZATION FORM
Date:'
me of Property owner Applying for Permit: Name of Authorized Agent for this project:
Dvner's Mailing Address:
'hone Number L
%7 0 UT
A ent's Mailing Add
�1e
Phone Number filQ qq1
A.U- q�3
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
>r and obtaining all CAMA Permits necessary to install or construct the following (activity):
kxAcl�pt &A f�,tf- - (-)ti f6 ((&,A -Ns Jz d ►Pdt4b,,A-/ o 143 Ae v\ . ;
L
or my property located at
i A Wraq ;�_ / �-r
its certification is valid thru (date) �6��y� o� 24�L'
�4,(C, �
Property Owner Signature Date
�U WO
ff9 m&v\ a

l -- be/, v0r
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
f �ti I hereby certify that I own property adjacent to 1� -F ��� Ad,j ' s
(� (Name of�Property
rOwner) I �,
property located at_ 1 `� ��Qc Y� Ie j W l � �i � vGJelj-%A le lye�y� '�/�
(Lot, Block, Road, etc.)
on A&40 , in 0 Cec IA -�S /<J2c,��j , N.C.
(Waterbody) (Town and/or County)
Applicant's phone 0: Mailing Address: a-Sl a, . lk�L&�XRV� �J
1,0-exOwA. Ik 15o�-C,
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal.
----------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by property owner proposing development)
lq� � t q o 1�� �11A W'�A
Y�
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
ZW- �4
Mailing Address Signature
�J4�x�,\ , SPA ion PC, tprx L -DC', w �'

—b (IVe%
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to7ZcQ i Qc' S S -s
(Name of Prop" Owner)
property located at ©C W-/V S f 4 W�- s � �1 V)
(Lot, Block, Road, etc.)
on !�1 �� c ()Cy *4 �- in (0 C R " � / I.,
(Waterbody) (Town and/or County)
Applicant's phone #: ���"b�?� -W�v Mailing Address: �� a . �� JV� &
r—
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by property owner proposing dew10 ment
I ��
�; �, A, 12 C (�
�\, �)RaV6 6� c
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
Mailing Address Signature
City/State/Zip Print or Type Name

��3 0�8�J

SANDBAG REMOVAL NOTICE
TO WHOM IT MAY CONCERN:
Ir► QF t�VCA�;O"\
, give permission to
LJ A� � of Ili C to act as
my agent irk my behalf in obtaining a LAMA General Permit to place
sandbags as a tem orary erosion control structure in front of my
property at 5-VC V, ,�Ic �[J, U) ` &,�\, �k
I, Ktl ,CIA 6v� , have read the
specifications in 15A NCAC 7H-1700 and understand that the sand
bags may remain in place for up to years after the date of
permit approval. I understand that I will be responsible for removing
the sandbags within 30 days after that period or at any time that they are
determined by DCM staff or its agent to be unnecessary due to
relocation or removal of the structure. I will also be responsible for
removing any damaged sandbags during the period they are authorized
to be in place.
I also understand that the removal of the sandbags shall not be
required if at the specified date for removal they are determined by
DCM staff to be covered by dunes with vegetation sufficient to be
considered stable and natural.
AUTHORIZED SIGNATURE:
HATE q/aGk�

V\�