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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
el F. Easley, Governor Charles S. Jones, Director
Authorized Agent Consent Agreement
William G. Ross Jr., Sec
19NT7ND2J is hereby authorized to act on my beha
(Printed Name of Agent)
�r to obtain any CAMA permit(s) required for the property listed below. The authorization is limited to t
c activities described in the attached sketch.
TION OF PROJECT:
ERTY OWNER MAILING ADDRESS:
a.8sL}(o PHONE NO. Q 10- Sn �l7ap
)RIZED AGENT MAILING ADDRESS:
y n
PHONE NO
J.,, ,.r o.... ... �1... __ ✓ .i / /A
-3.

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to _j O r- M `1: ()l A is
(Name of Property Owner)
property located at 1114 Ro a �, ` op � k , CtR
(Lot, Block, Road, etc.)
on FVk'1?I-- �Jr- C^ r , in , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: ylo Rio 17oo Mailing Address: 5904, E. 5?1?oNgp&L )aO�
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
R� 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
for Permit)
X J-,? 2 E .sAyejtJ(�NltG 1 iffel
Mailing Address
(Riparian Property Owner Information)
Signature

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOOREVG PILINGS/BOATLIFTIBOATSO USE)
I hereby certify that I own property adjacent to _ Sa" NN A 's
(Name of Property Owner)
property located at I N4 Rl*)_M `&M Cik
(Lot, Block, Road, etc.)
on _ EV aE_.. r. C Rt F— in _ IS to pzpm 5 t= ckL�-? , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: Ci % Sn-i7en Mailing Address:_'` E. S) J 1 7�If%A
He has described to me, as shown below, the development he is proposing at that Iocation, and, I
have no objections to his proposal. I understand that a pierfmooring 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
I do wish. to waive that setback requirement. ! Fo (� Ly � o -7
P.
DESCREI'TION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individualproposing development)
(Information for Property Owner Applying
for Permit)
SA;� E. JUC-.H lu- -72 kQ
Mailing Address -`
Information)
Signature
�xx��v ttl_F i,)C 59
Ci v/Stnte/7m
WC--' H0-5G-FS— PF--FS---r DEr4 -r

licant: J oil ti S�� ��� Permit #: 1 -
SQ
:vibe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id in your Habitat code sheet.
tat 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)
Dredge ❑ Fill Both ❑ Other ❑
3�60
7 (�
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 ❑

RI CONSTRUCTION
145 VIRGINIA LANE
ADS FERRY, NC 28460
[phone]
1550 Can)
BankofAmerica
ACH R/T 053Wo708
66-19-530
DO9464u■ 1:053000196,: 0006505219901i'
�I
9464
$
�a
� DOLLARS
8
AUTHORIZED IGNATURE