57557D - Murray

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Bevery Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date j j- 6✓ 1 1
Name of Property Owner Applying for Permit:
Mailing Address:
11c� P��k wav
I certify that I have authorized (agent) fi I II ' d M to act on my
behalf, for the purpose of applying forandobtaining all CAMA Permits necessary to
install or construct (activity) ' (i G L l Ya t �l
at (my property located at) 1 6- 1
This certification is valid thru (date) /Z 3�/Z
Property Owner
Date

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORIIVG PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to Irt �?L!�a �'s
/ (NaMe of Proper Owner)
property located at C ! i� ��ht ,�j (V c
(Lot, Block, Road, etc.) Q
on G�' Sauk 70 in _ ' 6A" ( gC'Gt� _ .�, N.C.
(Waterbody) ('Town and/or County)
Applicant's phone #• '71 r 3&, 7 ,215 Mailing Address:
'72 !76r %�C7'.
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.)
I do not wish to waive
14 _.
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)
110�- A �arKway �r,
Mailing Address
N& .2
City/state/7.in
Signature
X ,/jrr .-, t #2 : el /--., - �
Print or Tvue Name

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Permit
e:
z
;cribe 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
itat Name
DISTURB TYPE
Choose One
Disturbance total
includes any
disturbance.
Excludes any
Disturbance
total includes
disturbance.
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 ❑ Fill ❑ Both ❑ Othe
22
22
■ Complete items 1, 2, and 3. Also complete
Item 4 if Restricted Delivery is desired.
■ Print y ur name and address on the reverse
soth -roe can return the card to you.
■ Attach. his card to the back of the mailpiece,
or on the front If space permits.
1. Article Addressed to:
b, � - tf5
0/ 3 A!� ✓A ^C t 51t-
V 4 r(Vt e, , 'V(-
-�- �2 7sa C
A Sign re
X ❑ Agent
❑ Addressee
B. Recei by (Prin Name) C. Date of Delivery
D. is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Service Type
llill�Genlfied Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? pft Fee) ❑ Yes
2. Article Number 7010 1060 0000 8469 3179
(Transfer from selVirxi— ,
LPS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540
Dredge ❑ Fill ❑ Both ❑ Other ❑
■ 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.
1. Article Addressed to: