57572D - Coffey

CAMA / J DREDGE & FILL
i E N E RAL PERMIT Previous permit #
New .❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
)rized by the State of North Carolina, Department of Environment and Natural Resources I-Zou
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
Rules attached.
it Name 1 1J Project Location: County Y-W-o15vv i i 1,
Street Address/ State Road/ Lot #(s) l
----- id ` Stated ZIP z+c k.E"4'1 1a \y -
f Fax # () Subdivision
red Agent s ? �Lj1 CC6 prY CsityU(J(LI& Ise L?Xta aL ZIP
cW JEW ©_PTA ❑ES ❑PTS Phgne # 2q River Basin 1)M
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body (nat
ElPWS: ❑FC: iA,b101.�p
yes no) PNA yes / no Crit.Hab. yes no Closest Maj. Wtr. Body lrt�W
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ding permit may be required by: IIJ I �A ❑ See note on back regarding 'River Basin

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGS/BOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to ct f'►'l D. Ca-6 's
(Name of Property Own r)
property located at /.ofi 3G The Pem'tisalq ,
(Lot, Block, Road, etc.)
on C-OMMel- C1 a l C—qO l , in 0,T 6, r �,('u.NS wiC CO, , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #:33(0—'Y807/05 Mailing Address: 29� ��tdle 1-me
,� V nlce�NC� 2-700&
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
A*X — 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)
2q('9 L"e
(Riparian Property Owner Information)
Mailing Address
S ignafure

US MAIL
CERTIFIED MAIL, - RETURN RECEIPT .REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner: Gl h t
Address of Property:
(L.ot or Street #, Street or Road, City 8c
®ceah /s /e- &6
County)
Applicant's phone li: $d- l03$ Mailing Address: ---- f3, , -Ife Lgr —
_1/GUn C e A% —
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this permit
has described to me as shown or) the attached drawing the development they are proposing. A description of drawing. -
with dimensioLns, must be provided with this letter.
II have no objections to this proposal. I [rave objections to this proposal.
If you bave objections to what is being proposed, you must notify the Division of Coastal Management (DCM)
in writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal DriveExt.
Wilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no obeeclion if You have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, clock, mooring pilings, breakwater, boathouse, or lift must be set back a minimum distance of
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.)
�`k I do wish to waive the 15' set back requirement.
1.
I do not wish to waive the 15' set back requirement.
(Prope ner nfo • tion
gnatu. /1
Print or Type Name
Mailing Address
r:-, i Q4-- 1 7-
or Type Name
Mailing ddres>s
City / State / Zip
rttyy Owner Information)
/�

Beverly Eaves Perdue
Governor
Date: 2�
fi
A��j�r
NCDENR
North Carolina Department of Environment and ;Natural Resources
Division of Coastal Management
James H. Gregson
Director
AGENT AUTHORIZATION FORM
Name of Property Owner Applying for Permit:
jaanuva D.
Mailing Address:
2 ,% avi 4C c L aH e
kto4tCe- , /VG a7401.,
Phone Number: (33�k 4eeo -1a38
Dee Freeman
Secretary
'-�4I certify that I have authorized (agent) Qh to act on my
behalf, for the purpose of applying for and obtaining all CAMAA P, ermits necessary to install or
construct (activity) a 4.W-1 b�' /I t t cam"
at (my property located at) 36 2 A�►'i,nS--(a (mac eah (5(C
This certification is valid thru (date) U1?��1��` �� ;�•
Prooei`fy Owner Signature 61U / Date

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Division of Coastal Illlgt. Habitat Impact Computer Sheet
I- -,-
icant: , amp Permit #:
:vibe 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
1
r 3
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 ❑

RYAkl�Cle�di b �u�a�leo,eo m
D. CO ER
NCDL 8375610
PH. 910-4434829
P.O. BOX 1393
SHALLOTTE, NC 28459
PAY TO AIC /D EN/L
66-7704/2531 9526
DATE / / �—I J
r DOLLARS �e �`
State Em to ees' Credit Union-
.
Supply, NorttuCarollna
MEMOiNs7� /yice AP
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1:2S3"?0491:086143200911' 9S26