57332D - Ackerman

RZ_6"WA Resources
Carolina Department of Environment and Natural
Division of Coastal Management Dee Freeman
James H. Gregson secretary
terly Eaves Perdue Director
vernor
AGENT AUTHORIZATION FORM
Date.2/__�
,me of Property owner Applying for Permit
caner-s Mailing Address:
It
phone Numbef Jig d
Name of Authorized Agent for this project;
Agent's Mailing Address:
Phone Number 9ro T`
o act on nzy behalf, for the purpose of applying
certify that
I have authorized the agent listed above t
and obtaining aii CAMA Permits necessary to install or construct the following (activity
far _ I A
a?,,/�
(my property located) at
phis certification is valid thru
Date
operty owner Signature

DIVISION OF COASTAL MANAGEMENT
AW AkUNT RIPARIAN- PROPEI�T'u]WN R S J ATUNIENT
I hereby certify that I oxn property adjacent to h .yi ►. a '2'�
's
(Nance of Property Owner)
property ?ocated at b �S �a-
/(Lo lock, Road, etc.)
N.C.
on i ( le —al
(Waterbody) (Town and/or County)
Applicant's phone #: Mailing Addzess: —64
He/She has described tome as shown below the development be/she is proposing at that to cation,
and I have no objections to the proposal.
------ -- --------- --------------
DESCRIPTION AND/OR DRA'R'ING OF PROPOSED DEVELOPMENT;
(Individual proposing development mustfill in description below or attach a site drawing)
Cahe,►h.�'t� 1i yC� ..� 1
L* otdp
If you have objections to what is being proposed, you must notify the Division of COastHl tYlaaagentent (DCK in writi
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext. Wilmington, NC
DCM representatives can also. be contacted at [phone].
No res onse is considered the same as no ob'ecllo►t if you have been notified b Certified Mail
Vpener, reformation)
0
print or Type Name
jYkft�
Mailing Ad ress
(Riparian Prppe � ipformatio )
Signature
Print or Type Name
MaIn ddress

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARUN PROPERTY OWNER STAl'EMt ENT
�vriF' $i4�1/
I hereby certify that I own property adj acent to
property located at /4 �.
iS
F (Sot, Bloc Xoad, etc.)
oni>I U �P1 in , N.C.
(Wate ody (Town and/or Cou ty)
Applicant's phone #: MailingAddress:
He/She has described to me as shown below the development be/she is prop sing at that iocatiou,
and I have no objections to the proposal. -^
------ --------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT,
(Individual proposing development must f ll in description below or attach a site drawing)
1
c'oncr�f ,�l�b
If you have objections to what is being proposed, you must notify the Division of Coastal MauagLweni (I)CM) in writing
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext. Wilmington, NC
DCM representatives can also be contacted at (910) 796-721%
No response is considered the same as no ob'eciion if you have been notified by Certified Mail
(Property er ormatioia)
Si
Print or Type Name
Mailing Address
(Ri arias Property Owner luformation)
i ature
print o�Ty Name
Mailing Addres,
t _ ,Il . �

Message Confirmation Report
ame/Number
912522473330
age
4
tart Time
- MAY-02-2011 01:1OPM MON
lapsed Time
00' 36"
ode
STD ECM
esults
[ O. K]
MAY-02-201101:10 PM MON
Fax Number
Name
state of North Carolina
Department of Environment and Natural Resources
Wilmington Regional Office
Beverly Eaves Purdue, Governor
FAX COVER SHEET
Dee Freeman, Secretary
Date' S' L " // No. Of Page$: pxcl ding cover) 3
To: From: v '
Co: CO: Dlvlslon of Coa till Management
FAX # FAX#: [phone]
REMARKS:
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THIS NOiE IS LEGALTENDEq
♦•O/R'ALL DES BTS. PUBLIC AND PRIVAT.
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THIS NOTE S LE -AL TENDER
FOR AA, DEBTS ,I
PUB IC(ApN D�PR�IVATE
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THIS NOTE IS LEGALTENDER
FOR ALL DEBTS, PUBLJC AND PRIVATE
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GE 78044613 B
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THIS NOTE. IS LEGALTENUER
FOR ALL DE�B[TTSS. PUBLIC
� PRIVATE
( AND
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y
FOR
G I s a,,,m of NR U.W S..
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C Divisi-on of Coastal P09t, Habitat Impact Computer Shprt
plicant: �,�/�� (��'� Permit #'ql9
xe: I
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
ind in your Habitat code sheet.
bitat 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)
�C2
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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑