57570D - Cox

CAMA / _I DREDGE & FILL
i E N E RAL PERMIT Previous permit #
New .—Modification El Complete Reissue El Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources �7 ` 1 6o � ' 1�
oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC —f'H l!
i� Rules attached.
Name Project Location: County EYV 11SW \
State N C ZIP Z :?t' I Z_
(�) Li! iF' - 03 21 Fax # (_ )
I
!d Agent �1ii ✓�� ��� ✓.Ft
Cw _, EW j,� PTA LAS
❑ PTS
OEA HHF �❑ IH ❑ URA
❑ N/A
PwS: ❑
yes / no PNA yes (no, Crit.Hab. yes
Project/ Activity
length
f length
number
ead/ Poprap length rib
avg distance offshore Q /
max distance offshore��
channel
cubic yards
-amp
Ouse/ Boatlift
i Bulldozing
-WIMIWD
line Length iT{-il
not sure
yes no
ags: not sure
yes no
:orium: n/a
yes no
s:
yes no
r Attached:
yes no
Street Addr<<ess''/ State
Road/ Lot #(s)
I J J Y\ Tb
Subdivision r4 A
city A b_"" C�. AC zip ZgH
Phone # (9 (h) 6 19 - d lx5S River Basin LU 6
Adj. Wtr. Body QL1As (nat
Closest Maj. Win Body-- Ai
ding permit may be required by: -{ ❑ See note on back regarding River Basin
�- I I a L1 1-7 n n A,A A I 1 1,11. I. i 1 F71. 1 '1--A I, A I A A Lg , l'.-(

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ow

NCDER
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
AGENT AUTHORIZATION FORM
►ate:
lame of Property Owner Applying for Permit:
0
failing Address:
3960 LJOo-1011AvfAJ Gi
dLfrn MQA -5 , /U (. a-1 0 12-
'hone Number: (334) -1 1 1. 0.3 2- /
Dee Freeman
Secretary
certify that I have authorized (agent) A 6/ &24&4 to act on my
ehalf, for the purpose of applying for and obtaining all CAMA Permits necessary to install or
onstruct (activity) AP ff alkkwA a4
t (my property located at) /30 SOA�6, rd s�
his certification is valid thru (date) D
'roperty Owner Signature
Date

bL44 Vl . .... . .
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOA TLIFTIBOA THOUSE)
1 heroby certify that I own property adjacent to Bob Cox 1:3
(Name of Property Owner)
property located at 130 Sanford St ,
(Lot, Block, Road, etc.)
on Canal , in Hoiden Beach
(Waterbody) (Town and/or County)
Applicant's phone #: [phone] Mailing Address: 3900 Woodhaven Ct _
Clemmons NCs 27012
He has described to me, as shown below, the development he is proposing at that location, and, I
ha'vt iiu Ubicaions to hid proposal I understand that a pierlmooringr pilings / boatlitt / boattome
must be set back a minimum distuuce of fifteen feet (19) from my area of riparian access wiless
waived by me. f you wish to waive the setback you must initial the a ro riate blan Ic
below.
I do not wish to waive
I do wish to waive that setback requirement. W
'17
DESCRIftION ANl)/OIt 1litAW' IN .,G OFPROPOSEDu—'VELOPMENT:
(To be filled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
Jf00 C
Mailing Address
GyL � matJ 5 , N-l' a 701L
City/state/Zip r
L
(Riparian Property Owner Information)
Si .; ature
DoJ a �Print or Type Natne
-? a /e L. I /„ 6 -?, l

srn1,D bf,4.1 vf.1t_
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORIIVG PILI,NGSIBOAI Z.IFTIBO,4 TUOUSE)
I hereby certify that I own property adjacent to Bob Cox
(Name of Property Owner)
property located at 130 Sanford St
(Lot, Bloch, Road, etc.)
I
on _ _ Canal- , in Hotden Beach
, N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: [phone]
Mailing Address: 3900 Woodhaven Ct
Clenrions NC. 27012
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
0-1 do wish to K,aive that setback requirement.
-------------------- --
DESCRIPTION AND/OR DRAWING Ok PROPOSED DF VkLOPM9NT: t t
(To be filled in by individual proposing developmetet)
(Information for Property Owner Applying
for Permit)
3 `-06 lk)ov:QNAuFJ eT
Mailing Address
e, L-EM ryW,115 , !V - ('70/Z-
City/State/Zip -�
3 41 `LUa - 0 3 2-1
Telephone Number
(Riparian Property Owner Injgrmation)
6.V4 J `
J Signature
Print or Type Name
7 Telephone N.m h .P

Canal
a

Division of Coastal Mgt. Habitat Impact Computer Sheet
icant: r Permit -5
V-zz/t
I
,ribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
d 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
Dredge ❑ Fill Both ❑ Other ❑
c5�
Dredge ❑ Fill'V Both ❑ Other ❑
v
C/
Dredge ❑ Fill ❑ Both ❑ Othe
( !
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 ❑

JEFF N SIMMONS
DBA SIMMONS RENTAL II
130 VIOLET ST SW
POBOX 7
SHALLOTTE, NC 28459
Date
3379
66-112/531
$
Dollars 8
BRANCH BANKING AND TRUST COMPANY
1-E00-BANK BUT BBT.com
For 11f13`'ISO Qr .Sf -T `
1:053 10 1 & 2 11:0005 2979 2 2787