57448D - Teachey

CAMA / --'DREDGE & FILL A
1ENERAL PERMIT Previous permit #
;.New ,__'Modification L]Complete Reissue El Partial Reissue Date previous permit issued
Ized by the State of North Carolina, Department of Environment and Natural Resources 1100 , r 17-0c
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC Rules attached.
tN e
State ZIP
16) & Fax #
ed Agent
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0 PWS: EIFQ
Ifn'ol PNA yes/ a_67> Crit.Hab.
yes /' mod
Project Location: County �StM4,r—
Street Address/ State Road/ Lot #(s)
Subdivision
City 511V-74-1
Phone# River Basin6Fe
Adj. Wtr. Body Co -;-CA nat i
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Closest Maj. Wtr. Body 44 P Sy Ure5
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not sure yes
,s: not sure yes '01�
riurn: n/a yes
yes
3� ", / 7 "1 T
ing permit may be required by: See note on back regarding River Basin r

r

2013-Jan-31 02 38 PM bank of america 9103281491 1/1
ADJACENT RIPARIAN PROPERTY OWNER STATEAAENT
1 hereby certify that I own property adja nt to �j�T.' `� �Le i a
�. (Name of Property Owner
property located at ( �iY 'i�
on 1A �. e, 1n (AddresLot Slo o d, a .) N.C.
(Waterbody) (CltylT wn an r County)
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.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must H" In description below or attach a site drawing)
WAIVER ION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be get
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.
I do not wish to waive the 15, setback requirement.
n,. me InMrmatian) (Adjacent Property owner Information)
I
(Revised 8/182012)

11 13 02:30p Byrd Surveying 9199899300 p.l
Owner Information)
Print r-T i e N
Maili g Address
City tat
D
Tefophoge Nurpber
An.IACENT RIPARIAN PROPERTY OWNER SYATEMENT
I hereby certify that I own property adjacent to a of Property pwnep'
() !�
property located at (Address, Lot, Block, Road, etc.)
terbody) , in
on (C',tyfT I antUor C unty)
(Wa
The applicant has described to me, as shown below, the development proposed at the above
location.
1 have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION ANIYOR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing developmefrt must fill in description below of attach a site drawing)
10 }
K6f
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin 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.)
! do wish to waive the 15' setback requiremeni-
I do not wish to waive the 15, setback requirement.
(Adjacent Property Owner Information)
Signature �, y
/rV L J 4�OZD
Print or Type Name
sit, add 0�5 , 27.5 Z4
City/5fateiZip %�d� ���,
Teiep oneh Number

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date
P I
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent)^�"� (�� /`-!'� to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) w16'c(
4 �i -0
at (my property located at) �
(date)
This certification is valid ( ) /v—
Propefty Owner Signature
Date

rlicant: VlrJwa
e: _
13
r'-e�
0
Permit #:
cribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id 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 ❑ Fil> Both ❑ Other ❑
/11
Dredge ❑ Fill ❑ Both ❑ Other
O
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 ❑

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