54581D - Davis

a I CAMA / ❑ DREDGE & FILL ?`
GENERAL PERMIT Previous permit#
CNew ❑Modification [-]Complete Reissue El Partial Reissue Date previous permit issued
xized by tl-j State of North Carolina, Department of Environment and Natural Resources -7 n ,' 2� Co2stal Resources Commission in an area of environmental concern pursuant to I SA NCAC
ARules attached.
it Name y1UA 1C, iS Project Location: County Omlw
Z! L Street Address/ State(R�oad/ Lot #(s)
�VuTln� e �c� State ZIP Z451-+
( !�) L& j- tfqw Fax # ( ) Subdivision ►S� V,
zed Agent Cityl ZIP 4qq
i J CW ffEW ��PTA ES ❑ PTS Phone # ( ) River Basin 1/20
OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. BodyONO n
I PWS: ElFC:
yes /� o PNA yes no/ Crit.Hab. yes no
Closest Maj. Wtr. Body
f Project/ Activity 1-{4'VVtL•V,
)ck) length
n(s) , �7 �//
iiertcl -. / J�
:ngth
ember
id/ Riprap length_
,g distance offshore_
ax distance offshore
hannel
ibic yards
mp --
use/ Boatlift
lulldozing
2�rwavE U X !y _-
. �illti.►
ie Length j
not sure yes no
ls: not sure yes no
num:
n/a yes no _._.
I
Attached: _ ves!-
�XI
Miii
►lys ahtl
(Scale: I N
ing permit may a required by: ' (,' W I l— ❑See note on back regarding River Basin r
Pi_i j -1 rf\ n . -1 . I l .1 1.

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE) ,
I hereby certify that I own property adjacent to.�/9rh(PS 1. 9- s
(Name of Property Owner)
property located at
(Lot, Block, Road, etc.)
on , in _ N.C.
(Waterbody) (Town and/o County)
Applicant's phone #: 9 'C Mailing Address: 0 C- (
2 75,
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
, x A, I do wish, to waive that setback. requirement- -
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DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT;
(To be filled in by individual proposing development)
G,�nf iti�
--------------------------
(Information for Property Owner Applying
for Permit)
�-i5------
(Riparian Property Owner Information)
._--7
Mailina Address
/'. I 1 . - - -- -- rl:?- - - I,_ ill _„%

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGS/BOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to Jpftft T.
(Name of Property Owner)
10
property located at
(Lot, Block, Road, etc.)
on j+ r, rNj!4 , in 14, 6 , N.C.
(Waterbody) (Town and/or ounty)
Applicant's phone #: q 3 4!52j;: Mailing Address: 5[ 3 U AX 2.1 O
�ij3AeJd L/c.7).10 7
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
Y. r . I do wish to waive that setback requirement.
------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
vn-W
-E
(Information for Property Owner Applying
for Permit)
1�
Mailing ddress
IPA
0;—j voix
(Riparian Property Owner Information)
` Signature

C Division of Coastal Nigt, Habitat Impact Computer Sheet
licant: 5
ate:. � a
{'
Permit
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
ind in your Habitat code sheet.
:)itat 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 ❑
O
O
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 ❑
14 1

R.
MR. AND MRS. JAMES T. DAVIS S
NCDL 3206555 NCDL 3258022
5130 Nc. 210 919-934-5337
Smithfield, NC 27577-9126
Pay to the
order of
l>�
WACHOVIA
Wachovia Bank, a division of Wells Fargo Bank, N.
A.
For
1:05310
L6 26�: L 20000 12 43r-i L4
7714
66-162/531
BRANCH -95
Dollars
Mij,