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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
�1NT1�c�2r r�,ys-; .`c %%aX�1 is hereby authorized to act on my beh;
(Printed Name of Agent)
er to obtain any CAMA permit(s) required for the property listed below. The authorization is limited to
Tic activities described in the attached sketch.
\TION OF PROJECT:
Z-F-54 y
'ERTY OWNER MAILING ADDRESS:
`f Z1 H,.&J
2SS 3 �51 PHONE NO. rj jQ - —1joo
ORIZED AGENT MAILING ADDRESS:
a -V` o
PHONE NO. quo 3;�7 - 3 y �•;
I

. ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to ;S��y� H��:—S is
(Name of Property Owner)
property located at L- p-t5 yT)A 3
(Lot, Block, Road, etc.)
on CAuAt— , in 5�(2i UT ;' , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: Mailing Address:o(o v n ,,.5 42j
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
1� 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 (Riparian Property Owner Information)
for Permit)
Mailing Address Signature
f /S1

plicant: (� n
te:
Permit
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd in your Habitat code sheet..
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
)!tat Name
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts
amount)
/
Dredge ❑ Fi Both ❑ Other ❑
A Q
■ Complete items 1, 2, and 3. Also complete A. Signature
item 4 if Restricted Delivery is desired. X ❑ Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. B. Received by (Printed Name) C. Date of Delivery
■ Attach this card to the back of the mailpiece,
or on the front if space permits. —/
1. Article Addressed to:
PtNr1%IE o01-LAt3
334 tvA SArnE5 zo.
QAZ5RLZ , N C a$39-S5-4
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Service Type
Certified Mail ❑ Express Mail
Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number
(rransfer from service label) 7004 2890 0003 7344 5709
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540
Dredge ❑ Fill ❑ Both ❑ Other ❑
u.a. rustal JerviceTM
CERTIFIED MAIL. RECEIPT
edge (Domestic Mail Only; No Insurance Coverage Provided)
Ln
For delivery information visit our website at www.usps.com:;
Dredge

Bank ofAmerica -
ANTINORIvCONSTRUCTION ��IRGINIA LANE 19145 619530
SNEA�98460
10) 327-3475
PAY TO THE
ORDER OF:
MEMO
u'00 0006505 2 L99011'
49 211■ 1:0530001961: