57520D - Forest

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34'21'27 9' N '40'51W48;W elev 1 It
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RCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Bevft Eaves Perdue, Governor James H. Gregson, Director Dee Freeman, Secretary
Date /obb i
Name of Property Owner Applying for Permit:
M
Mailing Address:
?C-) 3,0.- 6 1 L
H&,,�f�,a,Q Pic- .2pYuO
I certify that I have authorized (agent) ail ��"/!'iC /I4 / l was to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity)
at (my property located at)
This certification is valid thru (date) /W -?////
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A D n ACF-Ilsr r z LAI PROP 1Y —!Iq--MR NO TIMCA110NIT {A � �r ER, FORM
ApplyingFor. Pc:.:.� F5 #yq..
�J.r iJ3 �Tfi#:Ir1fl.�r_ F!Gci►•�-G_ l-� !ri✓ v?�y� _ --
(Lot or &xmt # - Street of --Pcrad)
Ann A,z�--o,
,by cerdf.3 Z I v-i - pyopzrZy ate` to he aboyc L-e2 ��3t Cl �;dit�t`T �. -the �Edividual
ing ibr ibis pem.at has desci-i,3ae�,.d to ime as shams on the �.e,Sd. - f the ,�.' e fey
.rmroposiag- A -I s�do$$ � d2ti� -& ::n Y Lmne'Y.35iv3'7zz, Jai mold be p.-ovi�4e4l rfi�1�3 �aiis jeuer.
or e0l
lei .4 {'S '' 4a q P.''.�' ' ' Wizl' �.� 9ti..T� .+:yi ti 1T''. �ii..ALYCVi the
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y - °+.-.�a.. r irr: L:� °L �.i:Sa ..a192�ur`�.
3a$ me ac�i.fu �: of 1T fk-om xzviare-a't3a w��^�"a a - €a - Wah?ed iq ice. (:-I
79I h fad! W�dN:e11!e se-fbac?�y yem
do wL-sh t+A wave dme 151 ma -m-
1 duo AM wish to Waive the i Y sufthnack
Yam- CLDt i
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of or Sta-wt #, Street at toed)
-by eerfify a. -�' I orz i= _ Piy adjFaDaut W he above-$-c i s o' I pi-opexty Tine i-mB�v-jdual
ing for `dus pe s deg
te a" ° '__J ._ tea. _tad, ir: ah d naaa Fi 3 as, shu�.a's e rirs �.1ded rr�h ai iidjSS zits .
eemi;1-2 Drive end C_' ° is nT cam, q c
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F1'+i-"__ i :s^ nc :sniring- nffM,; b`�eai�t.4=fj by
4—s- - fob Waj`'+e 4the setback yom4 M !ui", �4 c`������,�1;m �s�c��
I do --A,-Lmh to -%tee the i 5' irk -.qaa
dO Mot Wish to Wave ire 1 Y s ' _-
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licant: FoR-e--:-NC-5aot4D
t1/3'120U
Permit #: Cj'� CjZp
-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
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 ❑

ALLIED MARINE CONTRACTORS, LLC 08-03
910-367-2159
92 HAROLD CT.
HAMPSTEAD, NC 28443
PAY TO THE
ORDp OF_
MEMO
Bank of America
ACH R/T 053000196
i 1 .
AUTHORIZED SIGNATURE
1100047001" i:053000196i: 00068474373aul