59160D - Afify

CAMA / _ DREDGE & FILL 59.
31ENERAL PERMIT Previous permit#
New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
rized by the Ss to of North Carolina, Department of Environment and Natural Resources
_oastgJ Resoutes Commission in an area of environmental concern pursuant to 15A NCAC
Rule, attached.
it Name j Project Location: County �J/L�J ;14 A/
lM Street Address/ State Rgad/ Lot-#(s)
jd i t Stateil%L"_ ZIP l 6 U ?i►• -C.t Ot
Fax f( Subdivision Oq
:ed Agent City Apt lgojoj,;�t�ZIP 2
[I CW W &PTA ES PTS Phone # ID � 7 River Basin-
❑ OEA ❑ HHF -❑ IH ❑ UBA ❑ N/A
Adj. Wtr. Body �; liV1�� SD-'Llr (nat /
❑ PWS: ❑FC: ,-
Closest Maj. Wtr. Body
165971 no PNA ee—l-) no Crit.Hab. yes / L/
F Project/ Activity G� �l 4_4
! -7 if
,ck) length 2-'
■❑■■■ice■■■i�1��
■■■■0fa30■:
i
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(Scale: !!/
❑ See note on back regarding River Basin r

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
ael F. Easley, Governor Charles S. Jones, Director
Authorized Agent Consent Agreement
William G. Ross Jr., SE
{� PM NCK1 MA2)Nr- Cn)�j 5i2JCi1CAJ is hereby authorized to act on my beh
(Printed Name of Agent)
ler to obtain any CAMA permit(s) required for the property listed below. The authorization is limited to
fic activities described in the attached sketch.
NTION OF PROJECT:
W)baE2 iF—A ID�t
2�t\ ToP�R%L
:'ERTY OWNER MAILING ADDRESS:
�) �iyCO PHONE NO. q\q- 4F�\4S- L,:;"'9L
IORIZED AGENT MAILING ADDRESS:
PHONE NO. !NL =Sj7 -34 7X
A,- �/ Xe�l-"--

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to M& ACl F `% is
(Name of Property Owner)
property located at q HL) J J G 1-1 >= PrrH bk ,
(Lot, Block, Road, etc.)
on STOMP 6C-,01,� , in Not--T 1 np-5A)L REF) u , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: 9 19 - V19 -159 L Mailing Address: 9 Hunr; Ek HiZaTH DQ
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 / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 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)
9 Hom-rz--e H D�
Mailing Address
----------------------------------------------------
(Riparian Property Owner Information)
X C'6 "MIJa5 i Lao
Signature

plicant: 10/.q-p/ F/f
Permit #: > 1'&Z)
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
Ind 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)
j
vv
Dredge ❑ Fill ❑ Both ❑ Ot
�Q
U+
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
COMPLETE•N
■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
COMPLETE THIS SECTION
A. Signal re
❑ Agent
X ❑ Addressee
B. Received by (Printed Name)
C. ate
D. Is delivery address different from Rem 1? ❑ Yes
If YES, enter delivery address below: ❑ No
1. Article Addressed to:
G%7�b5TA>`tT/1^1c l�f%T5(-�%2C�S
1 -5 8EacH RD .
LM
NC- ag 44/
3. Service Type
�ertifted Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 7004 2890 0003 7344 5570
(Transfer from service label)
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540