59192D - Latitude

JiCAMA / ❑ DREDGE & FILL
GENERAL PERMIT Previous permit# ®�
New ❑Modification []Complete Reissue ❑Partial Reissue Date previous permit issued
wized by the Stme of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pu uant I15�C
❑ Rules attached.
it Name G Project Location: County
i�+ C % 1 S _ Street Address/ State Road/ Lot #(s)
State�'JCiZIP2' / / — ced2kw k h LVb
Tax # () Subdivision
zed AgentA4 1- City ZIP
Cw F,Ew L,PTA - ES PTS Phone # IO River Basin
OEA HHF ❑ IH UBA ❑ N/A F y
Adj. Wtr. Body r/%� iJ �s C�"/(��(l�l, gnat
- PWS: � FC: /�
yes / no PNA yes / nab Crit.Hab. yes / dro,
Closest Maj. Wtr. Body �Ur CA %
f Project/ Activity
angth
amber
id/ Riprap length
g distance offshore
ax distance offshore N
hannel
bic yards
np
i di /L
ulldozing
e Length
not su yes
s: not sure yes
-ium: n/a ves
kttached:
rr4
ng permit may be required
AOC
V
❑ See note on back regarding River Basin ri
),Af - l //.., J ,o to .

tivd - v pJ/
z�
Sx
P-wr,
i,A
h

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORMG PILINGSIBOATLIFTIBOATHOIISE)
I hereby certify that I own property adjacent to z4� 3A T`s
(Name of Property Owner)
property located at D� ���«- b rvlz�
(Lot, Block, Road, etc.)
on �� �'""' , in %5-.d < �` �Q N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: �G�3�7 l �u�i Mailing Address: /+ Z �S
✓ t C /lI
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 / boadift / 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 most initial the appropriate blank
below.)
^ I do not wish to waive
1 do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing developmwnt)
J
(Information for Property Owner Applying
for Permit)
/,JA
u �4 &A
Mailing Address
L, � , , /lfL Z gqqS
City/State/Zip
(Riparian Property Informatio )
jjd
7,
P-1" , ignature
nt or Type Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORMG PILINGSIBOA TLIFTIBOA THOUSE)
I hereby certify that I own property adjacent to e ProP�fy l�e ✓ �' `s
(Name of Property Owner)
property located at Calralkl- grfS
(Lot, Block, Road, etc.)
on in
(Waterbody) JTown and/or County)
Applicant's phone #: 00 36 7 Mailing Address: & !,f' Ox 21 ! S-
15�) r � C, Y xc 2844I ,
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 mast initial the appropriate blank
below.)
IV I do not wish to waive
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To befitted in by individual proposing developnwnt)
-------------
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit) ,
q ffp,4 �O &Y- Z /1,5'
Mailing Address rr! /,� Signature
City/State/Zip Print or Type Name

Aft
MODWR
Nort CVOWWa DepatMntof Erfv. " and Natufal. ,
mvisioo of coasul managemrd
_ ' Erses Nrmw r" Arnim H7
fig r y Owawr ik; ptyi fat-. V ru :
O-ui
l` va
#Id
r
''" �X a $ k 6 � ` � �„S•M�. Pubn.w.ew,. .... .aa3.

plicant: �r
te: 157 � Z
Permit #: 5-9 % G► Z,
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd 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)
W
Dredge El Fill ❑ Both [I 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 0 Both ❑ Other ❑