59246D - Kozack

CAMA / DREDGE & FILL
GENERAL PERMIT
iNew -Modification El Complete Reissue ❑Partial Reissue
V
Previous permit #
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
j�;Mules attached.
nt Name kkyl� K-Q--,7-a G I(.,. Project Location: County �►�(f }'jS�n(� [ 1.
State Z45Lq
Fax # ()
j CW Q. EW 4 PTA ❑ ES C PTS
OEA 7-1 HHF = IH UBA _ N/A
PWS: ❑FC:
Street Address/ State Road/ Lot #(s)
152- Tuvla T,�-i ve,
Subdivisio N p1
City
Pfie 10 )J1b 5�� River Basin 1
Adj. Wtr. Body C r� �. (nat
/ - `" (Scale:
ock) length A
pier(s) Y. /
length
umber
:ad/ Riprap length
vg distance offshore
iax distance offshore
channel
}
ubic yara.
amp
>use/ Boadift
r M=wl- --SEE
■It11�N
MEN
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❑ See note on back regarding River Basin

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WAIVER SECTION

L16-03-eM( 10:02 From:
` To : 8429w6
r i r i l u
OR,
The purpeoe of this form is to provide proper notice to you as an adjacent rtponott propeay owner to the individual o
mdivkh" listed below, 'M LAMA General Permit epplieatiott W=G&M roquim thtat
Coastal MattaBW=t zonfintsation that a written stamrrtent has bees oblaitcd ° � provide the Aivi
indicating that they have no objection to the s�tod ProPe�
by certifKd mall of the �°� work 1 that the adjacent ripwinq property owners have beet[ r
contractor or other Wiv nan autho�f on t �1�� "artyo`""e �'
applicant.
This form wras stint is you. by the followhag 1MdWMW ah or company desigtwted by the applicant as as
atttborized agent:
s Signature
0
Name of Individual Applying for Penn[: __ 7Okl'1 io zr' _ �+
Address of Property_ ) S o�. c v k e. . '/ J"--
(lot or Street *, Street or
(City and County)
l hereby certify that l own Property adjacent to the above-refemnced'propetV. The individual applying for t
has described to tna as shown on the aagchded drawing the development they are proposing A description o
with dimensions. should be provided with this letter,
- I have no objections to this proposal,
t!'you have ob*dOas to what is being proposed. please write the DWkIon of Coastal _Manage,
Cardinal Drive Extensiou. Wilmington. NC 28405 or call 9io•796.721S within 10 days of MMipt of t
No respoRae is considered the some as no objection if you hove bees notified by Certified MaiL
WAIVER SECTION
I understuad that a pier. dock mooring pJTWV. breakwater. boat kouse or boat ilR must be a
minimum dha'tanct of 15, from my area of riparian access •_uah3s waived by me (U you wish to
setback, you mast initial the appropriate Mask below.)
l do wish to waive the 1 S' setback requirement-
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icier to obtain ant► CAMA Pannkai +a9Limd for #a Py tl %%d beia� 't'hs aL jh m . jion is FA
cifia �, doWSbed in the
:AIM OF PRCUSM:
MoPeffiY OWNM M`Ai1i.`M ADDRESS:
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'pplicant: o KQ Zn
J L
ate:
Permit #: 5q Z +(0
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurem,
)und in your Habitat code sheet.
abitat 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 Feel
(Anticipated f
disturbance.
Excludes any
restoration ar
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Other
I
I
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 ❑
O