62649D - Young

� CAMA / J DREDGE & FILL "' f N? 62
Previous permit #
GENERAL PERMIT Pp --e--
ANew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
orized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC o (r1 I L G
❑ itules attached.
nt Name I C V I n c3
_ State NC- ZIP Zvi
9Qr *t} ' Z5 L5 Fax # ( )
ized Agent
❑ CW p EW D PTA ES ❑ PTS
d
❑ OEA ❑ HHF _ IH __ UBA ❑ N/A
Project Location: County �tAkl k
Street Address/ State Road/ Lot #(s)
Subdivision T pa✓t; 1'-�&cr>
City Hf—, ZIP r��S
Phone # �, QW 7 7y - 75-tom) River Basin _
Adj. Wtr. Body if tp j D1!5� /C. 6&4Zb4-- ((nat
Closest Maj. Wtr. Body 7-0 e5 ► L t_�'IIIU
yes / no yes / no rlt. a . yes / no
A Project/ Activity r A, -]'./ -
PWS: FCQ
Oki C : H b
:ad/ Riprap length_
vg distance offshore_
iax distance offshore
channel
ubic yards
imp
)use/ Boatlift
Bulldozing
ine Length - W
not sure yes 49
igs: not sure yes 0 j
_rt
3rium: n/a yes n
yes
Attached: no
ling permit may be required by:
LJ See note on back regarding River Basin

pplicar,t: Yy�1 �a Q!%YL� Permit#: �ttaqcj—p
ate: i 0 3
ascribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
DISTURB TYPE
Choose Name 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
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 ❑

2170
67-219/539
2� 3 842
Date
d�iu• •.

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Scale: 1:100
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http://gis.pendercountync.gov/newgis/site/PrintTemplates/f

ADJACENT RIPARIAN PROPERTY OWNER
STATEMENT FOR CAMA MINOR PERMITS
I hereby certify that I own property adjacent to " 4 e- U jQ 's
(Name of Property O ner)
property located at 16
Address, Lot, Block, Road, etc.)
on in e'i Ce-✓- , N.C.
(Waterbody) (Town and/ Count
He has described to me as shown in the attached application and project drawing(s), the development
he is proposing at that location, and, I have no objections to his proposal.
(APPLICATION AND DRAWING OF PROPOSED DEVELOPMENT ATTACHED)
Print or Type Name
91Io-�(3I-00o
Te p one Number
/0--17---:�a 1 Z
Date

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property: / D S t� , n'C
(Lot or Street #, Street or Road, City & County)
Agent's Name #:
Agent's phone #:
Mailing Address:
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 the development
they are proposing. A description or drawing, with dimensions, must be provided with this letter.
'h 1 i have no objections to this proposal. I have objections to this proposal.
ifyou have objections to what is being proposed, you mustnotify 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.nccoastalmanagement.net/contact 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
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.)
_ PI P, I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
-XztL _
Signature
LA A-7 ( 1,4 Cw✓
Print or Type Name
rd ent Prope y Information)
r ture
Print or Type Name
4 sr"5'8
Mailing Address
Mailing Address