61551D - Mickey

N ° --. 61
CAMA / ' ❑DREDGE &FILL
'ENERAL
PERMIT
pA �, Previous permit#
New ❑Modification ❑Complete Reissue ❑Partial Reissue
Date previous permit issued
rued 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
ED Rules attached.
t Name
Project Location: County 4
sT'I
-40 amp
I raS� 1 fit. �< G�
Street Address/ State Road/ Lot #(s)
'j �; ((.�,y --r i v�
State ZI P I
J � (�1 r 1 L � ✓ i4
# 6k) 1H I
Fax # ( )
Subdivision t�
zed Agent s! (� r
t.i Y'
City d (n �S �'t l G��Gl ZIP 'LV ;
❑ CW O EW
� PTA ❑ ES ❑ PTS
Phone # River Basin Lu ►1
d
ElOEA ❑ HHF
[IIH ElUBA ❑ N/A
,,1
Adj. Wtr. Body l �, 6 nat
PWS:
❑FC:
I, J
yes / no PNA
yes no Crit.Hab. yes / no
Closest Maj. Wtr. Body W W
Body —
A Project/ Activity
ock) length
length
umber
!ad/ Riprap length
vg distance offshore
iax distance offshore
channel
ubic yards
amp
>use,/ Boatlift X
Bulldozing
ine Length 1. I
not sure yes no
igs: not sure yes no —
xium: ' \/a yes no 1
no-
r Attached: yes Xn!g
ling permit may be required by: J 1
1iI I^,.f, n.-1
t-
-rl-- ❑ See note on back regarding River Basin

W.
NZ
1 13
Property o�
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xF�R
�;
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
3everly Eaves Perdue James H. Gregson Dee Free
3overnor Director Secri
AGENT AUTHORIZATION FORM
ate:
ame of Property Owner Applying for Permit:
FeA C,KIP-
ailing Address:
"i 8 Cari, Qe s�;
A.)alKe-r-'fovj'V\t C-2-lo5l__
lone Number:/(0-'79ZI
;ertify that I have authorized (agent) lJr, CEC42eto act on my
:half, for the purpose of applying for and obtaining all CAMA Permits necessary to install or
instruct (activity) _�oa���- 1�/cioc_.k r�,car iau�'a+to✓�
(my property located at) _ 5C? coy�ca r'l 29yGj
his certification is valid thru (date)
I I ✓Aj Yl /-�-j - . -

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFT/BOATHOUSE)
M1
I hereby certify that I own property adjacent to -T-%—A I ''e 's
q (Name of Property Owner)
property located at 5 1 coy1cac-� S1
(Lot, Block, Road, etc.)
on l.Q>1� i no, , in bMnsw N.C.
(Waterbody) (Town and/or County)
Applicant's phone #-3-3 /K42^"R21 Mailing Address: gY3Y CaW PDCOV Rcta*�►
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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.)
I do not wish to waive
I do wish to waive that setback requirement.
---------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
Mailing Address
iA l l k42rAn ov M C -177Dsi
-------- -------------------------------------------------
(Riparian Property Owner Information)
/ ( c Signature
1� , (��'l t a

09r—, /e vc, /
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to Tedl 1, C is
p coName of Prope ty Owner)
property located at '
� I �-t��'1 CO � 5�
(Lot, Block, Road, etc.)
on ���' 0 t , in © U 64 co. , N.C.
(Waterbody) own and/or County)
Applicant's phone #:3 0—" l �w I Mailing Address: y gq r �1 r%
ow ��
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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.)
I do not wish to waive
I do wish to waive that setback requirement.
----------------------------------------------------------------------------------------------------------
!b DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
ys.
Mailing Address
. 1 !! f IA
(Riparian Property Owner Inf rmation)
L� e
Signature

L-1
24
uk, i :'.

Permit #: l I'rC, b
ascribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
Lind in your Habitat code sheet.
bitat 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
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 ❑
Bxl% -- 151

v D. COOPER
8375610
0-443-4829
DX 1393
�OTTE, NC 28459
:e Employees' Credit Union®
Supply, North Carolina
r r 41 'll
l 42
66-704/25,31 1154
DATE'3-Zl-i 3
$ 200`Do