59129D - Stafford

J'CAMA / ❑ DREDGE & FILL
GENERAL PERMIT Previous permit#
]New' .—]Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
t:T I!:�
,
rized by the State of North Carolina, Department of Environment and Natural Resources —4 , 1 •' uO
-oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
`- `` Mules attached.
it Name {lV1 �. AA � Project Location: County
!�V
5�} N1 ack.l-l\ bLr" Act Street Address/ State Road/ Lot #(s)
I t4ASb6 t State ZIP 2--t4ol 2-6 5-�k/fiS k b(li Vt-
P) Fax # () Subdivi ion N/j.
` tt 1 II (�
:ed Agent ( � �"i-ewk � j ytS-� ru,7 1 CL ,., City �C1t►-x IJ,(W".— zip t7 G
u CW 4� W *'PTA ES ❑ PTS Phone # jO )Z31 --44- S River Basin Lv fOl
❑ OEA ❑ HHF ❑ IH UBA ❑ N/A 0 I
❑ PWS: rno
yes / no) PNA yes
f Project/ Activity
Adj. Wtr. Body (lN /n� (nat//
Closest Maj. Wtr. Body AA Wyj
Crit.Hab. yes (no
/ F I / i v V
ick) length
)ier(s)
:ngth
ember
d/ Riprap length
g distance offshore_
ix distance offshore
hannel
bic yards_
np
ise/ Boatlift
ulldozing
e Length
.!
not sure yes
s: not su yes
ium: n/a
kttached: yes
ng permit may be re
(Scale: y�

10 2012 12:09PM Ricky Hewett Construction 910-842-7471 P.1
<NON?Ao-R • 2012 D 9
•v �r.� r. i�.n.�avo� .cwr .. .. yV117 b!'U1r Li V11 al�%-t7�C-'►/1
P. I
ADJACENT RIPAATAN PROPERTY OWNER N?ATENXNT
(FOR A P1ERlmoORRvG PM NG"OA TZ.I' ` /BOA ruousE)
1 hereby aerdfP that I aw11 property tAjecent to 11.1r 's
(Name of PropeM Owner)
property located at �►.. v'f.
7
(La , 9loa Road, )
on M11U6 �w�ax , izr _ 1t � _ ._ N.C. , .
(Watarbody) (Town and/or County)
Ho has desrlbed to me, u shown below, the development he it proposial At 69 location, and, I have
no Oliectlora to his proposal. I understand that a pier/mootiag pilings / boadift / boathouse must be set
back a mWmum distance of £Been feet (13"1 from lay area of riparian access unless waived by me.
(If you Kish to waive tho setback, you mast Initial the appropriate bleak below.)
I do not wish to waive
I do wish to waive that sotbaak requirement,
4.-
DESCRIPIIONANIVORDRAWUfGDTPPOPCKEDDMLOPbMIVT-
(To bajflled kr by brdlvidiialpsdpo#IVdevelopanextJ
rKaw
T*,'7
Wi�4i ry tlq�C�1'n � rt'}
U yea leave eb jectlons to whal It being Pr+pored, you most MW the Ptylsim of Coastal Meeseansnt (DCbt) to wrkt
witela 10 dlye otrsaetpt oitblt mallet. Cornapendewee should be ensued to 117 Ca►diaii Dttvs lrrt. WibniaRan. NC
"M rtprenntetirtt can also be toataeted at (0200 796-9115,
(iatbrmation for Property OwoerlApplicant
A.pptyme for permit)
Ma iq Addrew
�cj-�-
City tr up
TslephonaK b r 'J
(Ripariaa Prc pasty Owner ihmrmation) '
Print or Tne Naafis
C 6�4r.S
Telephone Namber

NCDENR
North Carolina Department of Environment and Natural Resourr,es
Division of Coastal Managemat
,-verl Eaves Perdue James H GrVon
Diredor
AGENT AUTHORIZATION FORM
le: 1244 i
me of Property Owner Applying for Permit-
r to- 5 4A 4KCKd
Wing Address
<V 44
Dee Freeman
Ser, A- tary
ertity that I have authorized (agent) Ae4,e-� to act on my
half, for the purpose of applying for and obtaining all CAMA Permits necessary to install or
nstruct (activity)
(my property lac
iis certification is valid thru (date)
Owner-Sigii*re Dole

Division of Coastal Mgt. Habitat Impact Computer Sheet
licant: �/Permit #: C1 l
l�
tribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id 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
temo imoacts)
impact amount)
temp impacts)
amount_
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:
CY1 iASo� l�l ica� Glue
375 0169mdf/1 O Z
rn j#ik. 15W4 Sc
Z 9 577
A. S' nature
X ❑Agent
❑ Addressee
B. Received b (Printed Name) C. Date of Delivery ,'-3D" —12—
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Service Type
ice
Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 7010 1870 0003 0026 7961
(transfer from service label)
PS Form 3811, February 2004
M
Domestic Return Receipt
■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
Drt • 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,
Dre or on the front if space permits.
1. Article Addressed to:
14A �Ja3 fob
I it. 17,14<< CQptok &h
102595-02-M-1540
A. Signature
7 ❑ Agent �
X t ❑ Addressee
B. Received by (Printed Name) C. Date of Delivery
D. Is delivery address different from item 1? ' ❑ Yes
If YES, enter delivery address below: ❑ No