59300D - Andrews

CAN! X / ❑ DREDGE & FILL V
?ENERAL PERMIT Previous permit #
New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
>rized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC �' u . �ZI V
� � Rules attached.
it Name �Q AM y- Project Location: County ' tJ i'1� ILA.
n ✓ U U r Street Address/ State Road/ Lot #(s)
StateW— ZIP �! �}YGV-41
( _ Fax # () Subdivision 04,
zed agent ��S Itats ity I li ZIP
i
CWEW PTA ❑ ES ❑ PTS h�ne� ( ��) �U River Basin
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body nat
❑ PWS: ❑ FC: _ 1
PVJA e� �.;� u�ti o� / „ Closest Maj. Wtr. Body Q
,f Project/ Activity
3 Ildozing
Nip yx Its
ie Length Sn
not sure yes no
gs: not sure yes no
rium: ves no
ing permit may be required by:
"l 1 1
❑ See note on back regarding River Basin
n. J . . ..

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Is::�i':��i�L'i!i►7/l/lam
(Address, Lo
t block,
/. �.i I -.t • /. i
... . .
The applicant has described to me, as shown below, the development proposed at the above
location.
I have no objection to this proposal.
l have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
;individual proposing development must fill in description below or attach a site drawing)
Fir
14' 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.)
I do wish to waive the 15' setback requirement.
i do not wish to waive the 15' setback requirement.
Information)(Property Owner
J &t doix - -
aj=
(Adjacent Property Owner Information)
Signe
Print or Type Name
Mailinq Address

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
...- .. -.. Maim lIYvIJI WLL'7?J►7/l/1�
• /. 1./_ / A"/. .1_
The applicant has described to me, as shown below, the development proposed at the above
location.
U� I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(individual proposing development must fill in description below or attach a site drawing)
loci eP1WeM&Tb
v
�eK
WAIVER SECTION
I understand that 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.)
Si l do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
Si ature S' ture
IT
Prt{�
t �� tTyp��—� -ppi �i Print or Type Name r
e, _ I ' % R' 6 0 /C e

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date ! - 1 - i Z
Name of Property Owner Applying for Permit:
Mailing Address:
1 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) a dpC_ ,
at (my property located at)
This certification is valid thru (date) L&Jff xx 9 /, X D .
.T
f.
Property Owner Signature Date

3� Cy&VeV-j S674t+ 0 - 1. 13 a
m

pplicant: ��} �� /j V V S
(Jl/li1 (n-1' 1 ILL Permit #:
ate:
9/ao � a
P 5cl30D I
ascribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
bitat Name
TOTAL Sq. Ft.
(Applied for.
DISTURB TYPE Disturbance total
Choose One includes any
anticipated
restoration or
temp impacts)
FINAL Sq, Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet FINAL Feet
(Applied for. (Anticipated final
Disturbance disturbance.
total includes Excludes any
any anticipated restoration and/or
restoration or temp impact
temp impacts) amount)
61v
Dredge ElFill ❑ Both El Other
! 1—7 2)
l�
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 ❑
Qx 1 lo = I -21b