61518D - Triple

LAMA / ❑ DREDGE & FILL M N?
1ENERAL PERMIT I� Previous permit #
!New El Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
3-9
•ized by the State of North Carolina, Department of Environment and Natural Resources
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
`1 ules attached.
Name 'YI `� l �t c �� IVF� Project Location: CountyT)", (�`. Ni( b-
I3� ( �, Street Address/ State Road/ Lot #(s)
U t151A-Yr StatetiC.. ZIP Lc C 1 a c j
Fax # ( ) Subdivision tJ 1A
tt�
ed Agent Azttt,t C�bt� �fr City uuc l> ' ZIP
❑ CW C- EW ] PTA ❑ ES ❑ PTS Phone # ( ) 41567 River Basin l(O
❑ OEA ❑ HHF ❑ IH UBA _7 N/A ^ n c
❑ PWS: ❑ FC:
/ no PNA yes / no Crit.Hab. yes / no /
Project/ Activity
Adl. Wtr. Body L1 114 (V C t Gi Y
Closest Maj. Wtr. Body_— LOi
(Scale:
���■/�.r'T7fit �■'�i■■■■■■■1■■■W' �' ■
ngth ■■■■\W■■■■r■■■■0 INN
■
offshore INN
MENIME is
■■r ■j■ ■■ �:�i�■:■ice■■�iii■
NINE 110via wNNIM. 111111
■■ ■■■11■ ■■
■■■■■N1■■■ ■ ■■:�
e yes no MM
■■�___■_��_�_■_■_�■_■■
e yes no I�'II�IMIT
■Maa■■■mllIVA
_���
igth
nber
I/ Riprap le
distance o
x distance
cannel
)ic yards
ip
se/ Boatlift
µ 1dozing
e Length
not sur
s: not sur
ium: n/
kttached: yes no % 1
ng permit may be required by � l ❑ See note on back regarding River Basin

�;66
al

HAND DELIVER
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to % r ,%!✓ ,[�, r �- �' 's
(Name of Property Owner)
property located at ( �1? 7 V Al --f
(Lot, Block, Road, etc.)
,fit � ju
1
on_ , in �S N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: / (?- Mailing Address: t
r
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 / boallift / boathouse
must be set back a minimum distance of fifteen feet G T) 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
(Riparian Property Owner Information)
1
f n \� Signature

��
Ag�
Am"
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue Braxton C. Davis Dee Freeman
Governor Director Secretary
AGENT AUTHORIZATION FORM
Date:
Name of property owner Applying for Permit: Name of orized Agent for this project:
/21!�%Cf��/%JfJC�
Owner's Mailing Address: Agents Mailing Address:
(Iire l?.511.q IV-' ;)7416 :3
Phone Number (J34')13a I2 - y / Phone Number (741)
1 certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtain g all CAMA Permits necessary to install or construct the following (activity):
For my property located at �� L�Y��1 S r< L ✓i�Cls l S ��` �fC�), /V C
This certification is valid thru (date)
TProperty OAL
wner Signature ' Date
One
127 Cardinal Drive Ext., VfJr, ington, NC 28405 NorthCarolina
Phone: [phone] FAX [phone] Interne:: ww %coasdrnanagement met, .s Aahma ly

US. MAIL
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
r
dame of Property Owner: ab zy t✓ di- F--�5e
address of Property:
(L.ot or Street #, Street or Road, City &
applicant's phone 39"!2�.5—Xilailing Address: 01
hereby certify that I own property adjacent to the above referenced property. The individual applying for this perm
ias described to me as shown on the attached drawing the development they are proposing. A description of drawin
vith dim=have
vided with this letter. 21/
ections 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)
n writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ex
Wilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No response is
-onside
red 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, or lift must be set back a minimum distance o
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 wi h to waive the 15' set back requirement. Ak"
I do not wish to waive the 15' set back requirement.
(Property Owner Information)
Signature
Print or Type Name
(Riparian Proper wner nformation)
Signnaat�u�r
Print or Type line
Mailing Address
Mailing Address

I
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r
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P
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8'10 0 '1'S`"'WDZZ

Applicant n r I e I V �Permit #: CI �Gj
Date:
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
'ound in your Habitat code sheet.
habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
tempIIimpacts)
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)
6
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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 ❑