61698D - High

Iriz
CAMA / DREDGE &FILL
ENERAL PERMIT Previous permit #
New Modification Complete Reissue ❑Partial Reissue Date previous permit issued
ed 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
ules attached.
t Name ilk +1' /U (j� ` Project Location: County le
f-► y t., J f i t j ��'�` W Street Address/ State Road/ Lot #(s)
State, ZIP Z&A`
( ) �,Z' ��'� Fax # ( ) Subdivision UYVI C&
zed Agent ? { V WA A-t r"' MA (i 4.1, Coll City u � ZIP
cw Ew PTA Es � PTs Phone # , River Basiny
d ( 4 t
OEA HHF =111 L UBA C N/A Adj. Wtr. Body A \ W W (natl
PWS FC: �{ � `W � J`
yes / no PNA yes,/ no Crit.Hab. yes d nO) Closest Maj. Wtr. Body A
A Project/ Activity I 1 f Vy\j Y )J&A U t" — Al --k V�I
lock) length
pier(s)
length
umber
:ad/ Riprap length
vg distance offshore
iax distance offshore
channel
ubic yards
imp
)use/ Boadift
Bulldozing
ne Length
not sure yes
igs: not sure yes
>rium: n/a yes
yes)
Attached: ( yes )
ling permit may be n
i cww,..—I r�wwa:4:w_
(Scale: ' fi

Division of Coastal Mgt, Habitat Impact Computer Sheet
flicant:
e:
Permit x:C�Q wvl`�
>cribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd in your Habitat code sheet.
)itat 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
Dredge ❑ Fill ❑ Both ❑ Other
l
1 'A
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 0 Both ❑ Other ❑

CTION INC 1211
'07 66-112/531
Date
$so
Dollars
109 2 2 19 to 700 L 2 L L

os le ��mm sb�'C

i2a13 iu:32 FAX IF940
bsorNME
North Carolina Department o l,Okondient and Natural resources
Division of Coastal Wriagement
Beverly Eaves Perdue Jarnes H. Gregson
Governor Director
AGENT AUTHORIZATION FORM
Date:
ame of Property Owner A13121ying for Per it�
fwner's Madfing Address:
�_
>hone.Number (7&) J
V1Doi
Dee Freeman
Secretary
Name of Authorized Agent for this project:
Agent's Mailing Address:
We
Phone Number i VY2 " --
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
'or and obtining
(my property located) at
to install or construct the following (activity):
This certification is valid thru (dat)
ax-� `
Property Owner gnature Date

27/2013 08:44 FAX
25/;2013• 09:53Lafayette Funeral Nome
/24/2013 10:60 FAX
[?] 001/00
(FAX)19108679100 P.U01i0C
isUU1.
"JACS1vT�R N PROPERTY Q%rip:� STOE IErtT
(FDRr� P p7w0"0ATLffT1sa,4Tff0&rM
I Eby comfy that l own pwpwty adj=nt ter is's
. ..... (dame off Ownw)
�► low at Lcaill4.�..�s 4. .
(XA f ork, Road. etc-)
on
owwy) (Twa ia4/or County)
Appil�atnt's plwna � �afgtag Addr+a�:
He ha dawxftd to zvk w Axnvn blow, do davdopniw be is p mposing at that .location, w4 i
to 04404M to hW pro'"I. I xaaderst and that a peer/wining p0Inp / bogiR / boalhouao
,tom be sat bark a miniawm diMM of fi'Roan htt (M ilom my 'NM* of rIPMAan acacas vnleas
vvoivdd by nvL (If you wb k to 1a111ve the xOtbwlt, ywr; Mwt Wtial the appropr%U bbnk
bsww.)
1do ziot wiait to waive
_ I dg wigh to waive the setback rWhumt.
(To bcjWed in bj btdt idual p, VwEV #Pwew#b'
(z i!�=��ivED
1 � r1f 4.0 D(',M VViLM;8NGT0N, NC
�1 JUN 2 7 2013
(bftmatium ion Prapet'�► r Appb g
tior prrmiC}
lvtta+littg Addteas
Telephone Numbo
(WpajM rMpa ly Ownw IM&Mation) .
pft at Type Nam

S/2013 18:55 FAX 16 001
ADJACENT RIPARIAN PROPERTY OWNER STATEM-ENT
(FOR A P1'.E.i 1*00AWG PLUNGSMOATLIFTIBOAMOVE)
1 hereby certify that I own property adjacent to N, S
(Name of Pro Owvner)
property located at
(Lot, Block, Rdad, etc.)
on in &t)Nr4��k, N.C.
(Waterbody) (Torun and/or County)
Applicant's phone #: L92—ZI i Mailing Address• ,
,L. t t T
has described to me, as shown below, tha develvprncnt he is proposing at that location, and, I
have no objectkms to his proposal, I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance. of fifteen Feet (IS) 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.
— -_ .--------
DESCRIPTIONAND 1ORDRA. WING'OFPROPCIf]bbEAW0)*MEN ,
(To beftlted in by individual proposing development)
126 °'
d e
UC4
(information for Property Owner Applying
for Permit) J,
Mailing Address
i„/) A I A I a, 3;1304,
city/statdrz
Tele�ll,Ci`te Number _ � 1' '�
(Riparian Property Owner Information)
Signature
Print or Type Name
TeleDhone Number

l/2013 09:03 FA%j001
�j S�
):� I AA & it Ae I f%