62640D - Hill

CAMA / VDREDGE & FILL
/ o. 62
GENERAL PERMIT
���/// Previous permit #^--,
New ❑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
i
int Name / -
❑ Rules attache
Project Location: County
s 2 6�✓ - 0 0 04
Street Address/ State Road/ Lot
State ,,A�C ZIP
h#f(s)
f
# l < <V )3& 7-- 5 7--tr6 Fax##I( )
Subdivision
ized Agent &'-?/`' f °'ram J c' ,l -
City �
❑ CW GW [PTA DES ❑ PTS
Phone # ( .,�,---� River Basin
d
❑ OEA ❑ HHF ❑ IH ❑ UBA _I N/A
Adj. Wtr. Body (,at,
❑ PWS: ❑FQ
yes,1 no PNA yes no' Crit.Hab. yes / �o
Closest Maj. Wtr. Body ✓ �' d V
A Project/ Activity
ock) length _
m(s)
pier(s) — �A N "4
length —(
umber — -
a Riprap length��
vg distance offshore_
iax distance offshore . _ _' F f
channel
ubic yards j
imp,
fuse/ Boatlift
Bulldozing
ne Length ^�
notsure yes
gs: not sure yes n
Oum: n/a yes no,�
yes / no
Attached: yes no
J
(Scale:
ling permit may be required by: _i ✓ / t �l ❑ See note on back regarding River Basin

ascribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
,bitat Name DISTURB TYPE
Choose One
TOTAL Sq. Ft. FINAL Sq. Ft. TOTAL Feet I FINAL Feet
(Applied for. (Anticipated final (Applied for. (Anticipated final
Disturbance total disturbance. Disturbance disturbance.
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)
a Dredge ❑ Fifl ❑ Both ❑ Other
Dredge ❑ Fil Both ❑ Other ❑
0
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 ❑

. .......... ....... I . ................ .
STRUCTION COMPANY, INC.
h. 919-934-6521
99 Buffalo Road
thfield, NC 27577
.4
%ND TRUST COMPANY
BBT BBT-c0m
i 5:L in 112 11:000 5
2975II4 6112
3589
66-112/531
DATE
........... . ......... .......
s

r
NCDEANR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis John E. Skvarla. II
Governor Director
Secretary
AGENT AUTHORIZATION FORM
Date
Nam f Property O iner Applying for Permit. Name f Authorized Agent for this project:
Owner's Mailing Address:
,a,� 9 J'�. I—I.JJR W
.:21_s 2
Agent's Malvin ddress
Phone Number Jig 2?,q Phone Number 9/0
i
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 instals or construct the following (activity):
For my property located at
This certification is valid thru (date)
-Al1_ 2-3.. �9
( roperty Owner Signature Date

ADJ
I hereby certify that I own property adjacent to r a. ti - s
. Narr�e ,of r perty Owner)
property located at
(Address, Lot, Bloc)o d c.)
on --— ^ %f /,� in N.C.
(Waterbody) f (City p*n and/or County)
The applicant has described to me, as shown below, the development proposed at the above locatic
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 attach a site drawing)
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 w
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.
(Pr rty Owner Information) (Adjacent Property Owner Information)
i/
Si atur Sig
Print or TXpe, ame i�_� Print pr T pe blame

l
I hereby certify that I own property adjacent to
property located at S
—1— (Address, Lot Bloi
on _1 _ — in 4"
(Waterbody)
2 s
K $ of P ooperty Owner)
:k e'.)
N.C.
ity/Tovffi and/or County)
The applicant has described to me, as shown below, the development proposed at the above locati(
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOgED DEVELOPMENT
(individual proposing development must fill in descriptionlbelow or attach a site drawing
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set b2
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to M
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.
7er.ty Owner Information) (Adjacent Property Owner Information)
i nat Q S' at
r
�-If C r �j ��✓/�SS��I�
Print or Ty eName / Print ° Typ,� Nae
.n r- n n A n A / I �l �i im