62561D - Scott

s�
CAMA / DREDGE &FILL Velo, N9
GENERAL PERMIT Previous permit #
❑New -Modification Complete Reissue ❑Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources _ t I , 2-0
0
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC �1
�C i ( Rules attached.
nt Name t -, yam Project Location: County �%6 wpy4 It
s(�t �1 �'�'}7 %L� Street Address/ State Road/ Lot #(s)
State zip �'J '
# Fax # ( ) Subdivision p
ized Agent City ' ' (�Y& Lt' ZIP 2b
d - CW ❑EW _'PTA ❑ES El Phone (��� )� 3' 33 River Basin
OEA HHF - IH UBA G N/A PWS: FC: ��"
Adj. Wtr. Body L.oil (nat
_
yes / no PNA yes / no Crit.Hab. yes / no
Closest Maj. Wtr. Body 1 LV VJ
A Project/ Activity }L A
(Scale:
ANNE
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■■■■■ ��"'7rSIM■■■■■■■■L'INNE 1
NO
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MIN
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IN
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i■■■ ■■i■■tQ ■■■�` %■■®■■■INEES
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OWNPOOMM MMEAMUMMUMMI M I
0 IT, t, �' 071-11L I
ling permit maybe required by: wo �� C(i✓tl� �U 1 C�r
❑ See note on back regarding River Basin
a (_1'

Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
Found in your Habitat code sheet.
iabitat 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/o
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 ❑

JERRY MILLS
JERRY MILLS CONSTRUCTION, INC.
k, 4670 MAPLE HILL ROAD SW
SHALLOTTE, INC 28470
910-443-2033
1ST BANK
,BEACH, NORTH CAROUNA 2 fi9
jVr_ _. 1D
32812,11 i:0S3L04568l:
2812
66-456-531

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�• `mot t` y `' ( _ �! v � "Y
J

13 11:59a • Americas Choice Training 9802197104 P. 1
111D-
R
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue Braxton C. Davis
Governor Director
Dee Freeman
Secretary
AGENT AUTHORIZATION FORM
Date:
►acne of Property Owner Applying for Permit: Name of Authorized Agent for this project:
s.
wets Mailing Address:
33 �,� aar,1 dA
I��(+� �cJ.�
g�: n0 �S &/+o� Z5 �OS
Agent's Mailing Address:
/ (l
.5c.2A e,vc. a 8(1)o
'hone Number r � �/S�'L `5 Phone Number Ab ]
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
3r and obtaining all CAMA Permits necessary to install or construct the following (activity);
'or my property located at
'his certification is valid thru (date)
Property Owner Signature Date

13 12:00p • Americas Choice Training
9802197104 p.1
NAND DELIVER
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FORA PIE"fOORINGPILINGSIBOATLIFTIBOATH'OUSE)
I hereby certify that I own property adjacent to �Lis r.-e— Au s
(Name of P partyOwner)
property IocRted at 4- 1) a)6c k 2� 1-5 -4."
(Lot, Black, Road, etc.)
on in ���t�'9 {P , N.C.
(Waterbody) (Town and/or County)
Applicant's phone#: 704`r7 U45-V Mailing Address: 'I'61(„fhesL 6N„el-N-rc.h ll,
He has described to me, as shown below, the development he is proposing ut that location, and, I
have no objections to his proposal. I understand that a pierlmooring pilings l boatlift / boathouse
must be set baok a minimum distance of fifteen feet (15) from my area of riparian access unless
waived by me. (if you wislt to waive the setback, you must initial the appropriate blame
below.)
i� I don wish to waive
I do wish to waive that setback requirement.
. DESCRIPTION ANDr012 DRAWING OF i'ROPOSCD li�L�.T►.OPIVI'ENT: '
(To beJllled to by individual proposing developmeitlj
(Information for Property Owner Applying
for Permit)
Mailing((Address
(Riparian Property Owner Information)
Signature
/ /� l�t:s;JcP�S�G
rite �'[t'Lax s Ua
Print 0 Tvne Name

JS MAIL �q
CERTIFIED INIM , - UTURNABCEIP1 -REOiIZSTED
DIVISION Or COASTAL MZ A,NAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER SWEWWNT ,
,me of Property Owner;
!dross of Property:
r
EM
r Street ff, Street or Road,
)plicant'sphone#: �Q�Lf--yr�-+S5( Mailing Address: 'R 11 !23!Qll T 0.,,,tirG.VA
nreby certify that I own property adjacent to the above referenced property. The Individual applying for this permit
s described to me as shown on the attached drawing the development they Are proposing. A doscriplion of drawing.
th dimensiq,(_rni st be provided Vi%jl ia-Lq=
I have no objections to this proposal. I have objectlons to tbis proposal.
You have objections to what is being proposed, you must notify the Division of Coastal Management (DCM)
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.
ilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No response is
n2idered the.ntuue as no obiection_if you have been notified by Certified Mail.
WAIVER SECTION
r<derstand ehet pAit'r, deck, mggring piiinge, b{ealSwater, vo�thqusc,,or lift must be set baok a minimum distance of
from my area of riparian access unless waived by me, (If you wish to waive the setback, you trust initial the
aropriate blank below.) , � . _
I do wish to waive the 15' set back requirement. DQM WILMINGTON, NC
1 do not wish to waive the 15' set back requirement.
AUG 0 b 2u13
rvperty Owner information) (Rip'=erty ivner nformation)
x � 5nature Signature
ntt or Type Name
lk� tAh�h
tiling Address
�,k A& &LPIS I J,C i
Print or Typo Name
i ♦ . �►Ilk
:h WWI _ v o.

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