62550D - Keith

CAMA / DREDGE & FILL r F
,"3 E N E RAL PERMIT Previous permit #
-'New _.Modification Complete Reissue ']Partial Reissue Date previous permit issued
Ozed 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 , j �. ,
ules attached.
it Name-1- ft }1l-�'i i iA Project Location: County-Nxa�
l' D F(t ATV-fZN 1 :)( ( that-C iA RO. Street Address/ State Road/ Lot #(s)
hlS f G►�I ` SAlk"1lA State {1�i' ZIP
6 -5-71 ! Fax # ( ) Subdivision
Ized Agent
d ❑ CW EW PTA —ES PTS
OEA HHF ❑ IH ❑ UBA C N/A
C PWS: FC:
City (.
Phone # ( )
ZIP
River Basin p4F-
Adj. Wtr. Body 6L Af k (7- 1 yo� '� 6%
yes i no PNA yes /� Crit.Hab. yes / no
Closest Mai. Wtr. Body � 1 VVVr%
A Project/ Activity r(l 1 � N; K_'L,i..- i_ tL-
lock) length 2.7x �c, ,
m(s)
pier(s)
length
umber
gad/ Riprap length
vg distance offshore
nax distance offshore
channel
ubic yards
amp
use/ Boatlift
Bulldozing
F-L(, -1-r�'
ine Length
not sure yes 0
igs: not sure yes o
Drium: n/a yes
yes
Attached: yes
ling permit may be required by: L l
. — . . — ... — - 1r -- "11 1 1 '7 n—
(Scale: I ' ':=
❑ See note on back regarding River Basin

Applicant: IU F t t
Permit #: /,����
Date: 1/Z�/I it l(
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
-labitat Name DISTURB TYPE Disturbance total
disturbance.
Disturbance
disturbance.
Choose One includes any
I
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/o
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts)
amount)
I Dredge ❑ Fill ❑ Both ❑ Other ❑ I I�� I
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 ❑

9394
66-30/531
-7 461
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A),,)Le)r,O S--Dollars
1? 705 S991's 09 39t,
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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to MOM A'-, J - K,_.i ►'M
(Name of Property Owner)
property located at 1a-1 CAkb; '[yai4 12Dc oeattc.
• (Address, Lot Block, Road, etc.)
on (31,Aq;�4� RiViE�-L in oE1uV &�R CD071y N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above to
x— 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 description below or attach a site draw
See (4-6E ' D
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish tc
the setback, you must initial the appropriate blank below.)
_ c I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Ow er Information)
Signature
Print or Type Name
3NSo 12,0
(Adjacent Property Owner Information)
Signature h'-�- ld:�r :- �.w�'- - t
'Ttt cm1 S • i 1 TO , ow ner�, mytta
Print or Ty e Name _

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: —711 o �' tA S `T �F 1 � r+ ion �� �.; v � ji'v 9c, Plz-opE
Address of Property:
Agent's Name #:
Agent's phone #:
iGl�cWC iVck. R.D,G%aV-o-1E P�NVGQ- f�v
(Lot or Street #, Street or Road, City & County)
Mailing Address:
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions, must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 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.)
_DQJ�L— I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
Signature Signature
'Itto mk-i �U • I l�trr
Print or Type Name
'telumhl 3 • JCS*TM
Print or Type Name
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