57458D - Prestage

CAMA / DREDGE & FILL
GENERAL PERMIT �� Previous permit#
�-New Modification '-I Complete Reissue 'Partial Reissue Date previous permit issued
iorized 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 LOC.,,
❑ Rules attached.
int Name �c 0 Project Location: CountyPC N c
;s 4 Street Address/ State Road/ Lot #(s)
Z State s-- ZIP ->
-ized Agent 4cr\5t-c,��,,e- J V^ L,
:d
❑ CW ❑ EW =, PTA -
ES IPTS
❑ OEA C7 HHF D IH D UBA I I N/A
I:
❑ PWS: FC:
yes /' 'Md,, PNA yes / no Crit.Hab. yes / no
Subdivision
City1 oF'S,-, (L- 1* ZIP Z Y4
Phone # ( ) ` - River Basin IfF/
Adj. Wtr. Bod(nat
Closest Maj. Wtr. Body
r l �
of Project/ Activity i -�4A�-
-rz n; t r 14gch,� NK14Et.
jock) length
rm(s)
- pier(s) iC5' C
length
lumber
ead/ Riprap length _
ivg distance offshore_
nax distance offshore
channel
=ubic yards
amp
ouse/ Boatlio j `i
Bulldozing
line Length
not sure
yes
ags: not sure
yes
orium: n/a
yes
s:
yes
r Attached:
yes
(Scale: I l►_
ding permit may be required by: t D (�,1 ❑ See note on back regarding River Basin
,_ .._ .,)) .,,L..

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scoff Q�r�f Faye
O 116 a
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SUG46-Me ft M From: A
i . 1
To;93294461
( omrtNy tf�t i oMn Prop�1►aiy�omnt to Je-QE18
oroP«b► baav0 at o ✓J
/U ��4hn L > N.C.
on to
The mpptiasm ham desartbed to me, as Mown below, the deveiopno" PmPoasd r tke Shove lvice"-
IL56 i hm r o otyeWon to 26 pmpau .
i h" oeleatlotM to" pop"
rdwl" pmpoft OL -Ova we MW AM to 0 - I sm - crow or Basch a oft *Swk*
Wm= is
i undws%Ml the a plat. dodo, ffoxtro FWVF, b0ositmum. M, or 2min must be met back a
mk*An 1m1 L , - of is horn my a" of r%adan a meem unres w&W by ma (it You Wi4h to waive
en oft* yaw mW kMd tlts appm" tm W&* bmbw )
l do rrieh taw" flan t s eettt & ngWW""tt
O. i de not whit to we %* the t IF oft"
i
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�� NS Ck
Print ar Tvao Name s i 0 _ _ 4
FXfi-09-2012 09:40 From:
To; 9329Wi
I heoar* that I own property sdJacent to �o�7 re
reby � s
7 IN"" of PropeRy ri
PMWY 10c" at
on
P.112
►
The applicant has described to me, as shown below, the development proposed at the above location-
,_ I have no objection to this proposal.
I have objections to this proposal.
DIIBCAiPTION ANDIOR DRAWWO OP PROPMED DFVELOPMGNT
(kH*vldual proposing deveiopmW must IN in desariptton aglow or attach a site drawing)
W61VFR_ SIC__QON
i understand that s pier, dodo, mooring piflngs, breakwater. bOstiwne, Rk or grain must be set back a
mW uun distance of lip from my area of rlparlan access unless waived by ma. {if you wish to waive
the setback, you must Initial the appropriate blank below.)
_ i do wish to walva the 15' satbnd: raqulromant.
1 do not wl8h to waive the 1 t5, "back requiremeM.
(AdjaaeMt Prowner Information)
XfOV gG
or

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date .1-;< `'l- 1�
Name of Property Owner Applying for Permit:
Mailing Address:
5 8 Ini6n SGhoo Road
I certify that I have authorized (agent) Pf f &1 11 e l4/►j/i to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits jnecessary to
install or contract (activity) _Au Hf ] k , Pe,(K 14 /6/ rC
at (my property located at)
,/3 T-oeT rt"I
This certification is valid thru (date) / — (- / J
Property Owner Signature V Date

pplicant: �l�p" �%,�5��{ Permit k S
ate: � _ 7 a
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.
(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)
DDredge ❑ 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 ❑

NOT VALID UNLESS MONEY OflDEp IS MACHINE IMPpINTED a8-490
NORTH AMERICAN MONEY ORDER 110109510
SECURITY FEATURES ON THIS DOCUMENT INCLUDES EN ON HE SIG- f
NATURE LINES GREEN IN .ABSENCE OF SECURITY SCREEN A THE BACK
1 PRINTED IN GREEN INN. ABSENCE OF THESE FEATURES MAY INDICATE
COPIES OR ALTERATIONS. 1..._—......_.
* *
PAY TO THE * irlu s �r am1d1 i, *
ORDER OF *. I
��sls�:.:
NO VA 10 OVHU E tHfi�E NC7 D U 5. OLLARS NO 'Jr
Purchaser/Drawer SignatureY._— _ -- ----------'-- 0,;
Payle Through /' .. �Bandirsl (% '-� '�-'�Address-------
Stratford, Oklahoma

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