62570D - Smith

ICA1VIA DREDGE &FILL '
3ENERAL PERMIT Previous permit #
4New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
sized by the State of North Carolina, Department of Environment and Natural Resources ��_
Zoastal Resources Commission in an area of environmental concern pursuant to I SA NCAC Z 0
❑ Ruiles attached.
it Name ul t+ KA Project Location: County ^ i 0. t
�Sc?7­� v f Street Address/ State Road/ Lot # )
Stated 1) ZIP ZU� l (� j :,
t
!' Subdivision GAi1/t
:ed Agent z P1 Ors l City ZO W�er
ZIP-❑ CW !EW PTA ElES ❑ PTS Phone # ( _ ) Basin
OEA ❑ HHF ❑ IH L UBA ❑ N/A
❑ Ill
yes / no, PNA
❑ FC:
ye no
f Project/ Activity
(�1'
)ck) length
n(s)
)ier(s)
I
mgth
amber
id/ Riprap length
g distance offshore
ax distance offshore
hannel
i
ibic yards
mp
—,- -
—
e/ Boatr f x �Z
y
3ulldozing
ie Length
not sure yes
gs: not sure yes no
es
rium: n/a yes
Adj. vvtr. Body '' n t
Crit.Hab. yes ,r�no •
Closest Maj. Wtr. Body L"J, © 5;0a'4
(Scale: AV /
Attached: / yes
ling permit may be required by: L ❑ See note on back reg
arding RiverBasin

plicant: (1 '�" (/� (n/� (� Permit #:
te:
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd in your Habitat code sheet.
,itat 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
l qq
li
Dredge ❑ Fill ❑ Both El Other ❑
Dredge ❑ Fill El 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 ❑

BankofAmerica 2435
STRUCTION, INC. ACH R/T W3000196
NETT LANE
RRY, NC 28460 66-19-530
ro7mililm
,%OrJC Pf- �2d
'"S"s ':0530001961: 23?01533??4B11'

V

CERTIFIED MAIL •RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORMA
Name of Property Owner.
Address of Property:
(Lot or Street#, Street or Road, City & County)
►� � p21YIS;}
Applicant phone #: 1�� 3��1 Mailing Address: 76a Nth
I hereby certify that i own property adjacent to the above referenced property. The individual
_applying for this_permdAim described to, measshoem an the attached -drawing the development
they are proposing. A desolation 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. Contact information for DCM offices is
available at www.nccoastaimangementneticontact dcm.htm or by calling 1-888-4RCOAST. No
response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
l'understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift 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.)
I do wish to waive the 15' setback requirement.
V__ I do not wish to waive the IS setback requirement.
(Property Owner I►rf Lion)
gnature
Print or Type Name
vou
Mailing Address
e &e 207s1
CitylState/Zip - — -
(Riparian Property er Information)
cam. -mot.
Signature
Print or Type Name
I b S (,
Mailing Address ,
QVState/Zip

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
(dame of Property Owner. 0 ith SM
Address of Property:(�� fl�
(Lot or Street% Street or Road, City & County)
Pp1o U -1 cb 0stz'U e4 vp'1
Applicant phone #: I�' L - 3`�`7'1 Mailing Address: 5�k bo r"t'z� l l
�ji�.iJ� �VL� 1'vz✓� `�
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_ he 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.
/fyou 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. Contact information for DCM offices is
available at www.nccoastalmangementnet/contact dcm.htm or by calling 1-888-4RCOAST. No
response is considered the same as no objeCtfon it you have been notified by Certified Mail.
WAIVER SECTION
I,understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift 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.)
(2� 1 do wish to waive the 15' setback requirement:
I do not wish to waive the 16 setback requirement.
Signature _
Print or Type Name
8o-3141i ad 7�
Mailing Address
70 7 y
CitylStatelZip
(Riparian Property Owner Information)
Signature
Print or Type Name
I K4_ w-,,.v-cck e4 f�
Mailing Address ,
City/StatelZip

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date Oci- 0 L5
Name of Property Owner Applying for Permit:
t_�2tt�
Mailing Address:
I certify that I have authorized (agent) �`� OxS� J l� to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at)
This certification is valid thru (date)
FV S, W14 %� WIAI'A -91
E
Property Owner Signature Date