63118D - Hedrick

63.
bAMA / A REDGE & FILL
NERAL PERMIT
ew ❑Modification ❑Complete Reissue El' Partial Reissue
Previous permit #
Date previous permit issued
zed 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&OKUles attached.
/�
Name / ?/ // �_ 1 Project Location: County_ l��;i �1'l
/�' 407 Street Address/ State Road/ Lot #(s)
State ZIPZ5�0�%f
ax,# (_) Subdivision
ed Agent 14l">" A-7"Z City 1-4i/ ��ri ZIP /
❑ CW C?IEW C+ 'TA IJS ❑ PTS Phone # ( ) River Basin �_ l'�
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body�l�r•� r,,%' (nat�
❑ PWS: ❑FC:�
Closest Maj. WtrBody
yes / PNA es / no Crit.Hab. yes / no
io. --�.
ngth
mber
.I
d/ Riprap length 2-0
g distance offshore Z L T
�...lferonrn nffchnro
ie Length
not sure yes
ling permit may be required by: /�/ ���_s��tJlt�/1±=+� S % See note on back regarding River Basin

ASLa"
cant: ( � ffC�/%' �L lt Permit #:
e:
cribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
rid in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for-
(Anticipated final
(Applied for.
(Anticipated final
itat Name
DISTURB TYPE
Disturbance total
includes any
disturbance_
Excludes any
Disturbance
total includes
disturbance.
Excludes any
Choose One
anticipated
restoration
any anticipated
restoration an
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts)
amount)
SDredge
❑ Fill Both ElOther El`/
Z -G
/ ZZ
Dredge ❑ Fill VKBoth ❑ Other ❑
3 Ov
3 v
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 ❑
Drel
SECTIONSENDER: (f CMPLETE THIS
•MPLETE THIS SECTION ON DELIVERY
Dreg 0 Complete items 1, 2, and 3. Also complete
ignature
Item 4 If Restricted Delivery is desired.
0 Print
❑ Agent
X
your%name and address on the reverse
Dre(
❑ Addressee
B. Received by Printed Name)
C. Date of Delivery
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
D. Is delive�ryq adre "' ❑Yes
1. Article Addressed to:
If YES,1Jl�(Vll t la��° Vv ��, PTO
5lIA,.,�/ti Z-4riC L)o✓1!1, 30

PAY
TO THE
ORDER OF
r"
Ki Cc jXC ZJ
Wells Fargo Bank, N.A.
North Carolina
wellsfargo.com 31` 1 (�
FOR ''IC.
11100000 19 2600 iM S 3000 2 L94 2086 L 70x09'96 Lu'
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XNA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
'at McCrory Braxton C. Davis
Governor Director
AGENT AUTHORIZATION FORM
Date: ! 0, 2' 3�- i 1
ame of Property Owner Applying for Permit:
ric�_
Wrier's Mailing Address:
13c� Bari , n5,cde 116010e
v)
'hone Number 67/01
John E. Skvarla, III
Secretary
Name of Authorized Agent for this project:
Agent's Mailing Address:
Phone Number( 5 / o) ) i l - 'S; / -/
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
br and obtaining all CAMA Permits necessary to install or construct the following (activity):
For my property located at
This certification is valid thru (date)
fa -a 3—i3
perty Owner Signature Date
RECEIVED
DCM WILMINGTON, N
D E C 1 6 2013

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A P1 ERMOOR17VG PHJNGS✓BOATLLFTBOATSOUSi
I hereby certify that I own property adjac ent to �� i i P C o �H� � lC= _ -S
(Name of Property Owner)
�
130 r\#r—Vie,
le
U (IA�, Block, Road,�-) '� N C. 1 in
aterbody) and/or County)
has described to me, as shown below, the development he is proposing at that location, and, I have
)bjections to his proposal. I understand that a pier/moonng pilings / boatlift / boathouse must be set
k a minimum distance of fifown feet (15) fium my area of riparian access sonless waived by me.
(If you wish to waive the setback, you =v& 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 bef&ed = by individual propmW level *m=t)
`P Qp\�tce b�Ekl� C1 16 �t c 1� I Q r
J
RECEIVED
DCM WILMINGTON, NC
:ormation for Property Ow oer/Applcant
Applying for permit)
3l (-1 Lip s, if Ys v;
ling Address
Z
DEC 1 6 2013
(Riparian Property Owner Information)
k ?
Signature
Print or Type Name `-'
_0/1r)-Q-�f-c2e/t/

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