57346D - Grigston

CAMA / ❑ DREDGE & FILL
'1ENERAL PERMIT Previous permit#
Kew ❑Modification El Complete Reissue El Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources �j L
:b'aastal Resources Commission in an area of environmental concern pursuant to 15A NCAC J//-
E 'files attached.
t Name Project Location: County �,�' rv,✓S�✓i ��
_ f3 P?/1 e L W. Street Address/ State Road/ Lot #(s) /3 �� T�s.✓A
-- — State
(2& f 2b -- 1yeFax # O_
ed Agent R 1 Cey Al/F :V e H
❑ CW ❑ EW ❑ PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF L IH ❑ UBA ❑ N/A
❑ PWS: ❑ FC:
yes no , PNA yes /�i Crit.Hab. yes / no
Project/ Activity
Subdivision
City //O ZW,PW ZIP 2 F%1
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g permit may be required by: 110 ❑ See note on back regarding River Basin nj

ACD NR
North Carolina Department of Environment and Naturai Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
AGENT AUTHORIZATION FORM
Date:
Name of Property Owner Applying for Permit: i
Mailing Address
Its 7-7 llya t) !----
_ 5rg.,j N a 7 3 3D _-
Phone Number: A9 t ?76 1 _6.d_.._.
Dee free,
Seen
I certify that I have authorized (agent) -R-- —1-e---r-�1-- Hi�wf-fi to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to install or
construct (activity) _ j0C
at (my property located at)
AC
This certification is valid thru (date)
Property Owner Signature
Date

PM
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v tt A I F: M VNI
2,3
it
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Page I

#Arjk, aA-i v4A-
ADJACENT RIPARIAN P120PERTY OWNER STATEMENT
(,l~ORA.PIERlM00.RIN(. PILING&B(LiTLIFT1180ATNDIISF}
i hereby certify that 1 own propCrty adjaccrit to t!(I�1�
(Name of i'r(ipet�ty O"Vvner)
property located at
(Lot. Block, Road, etc.)
✓^ j�( j 1 t t
on _- .. _ r ` ... _ _ : ir► -. . _ C lLi c� 1 .5ftql' ._.... N.C.
(WaterhodQy) Q/ n (Town and/or County)
Applicant's franc /t: ! MailingAddress.---- Q._JQ
_._.�a�. oast N � .>� 3�►
lie has cicwriL--I to me, as shown below. the (it-w0upment lie is proposing at that location, and, I
have no objections to his prop<isal. I understand that a pier/mooring pilings / butidi0 I buathuuse
must be scat rack a minimui t distartec of fifteen feet. (i Y) from my area of riparian access unless
waiaed by me. (If you wide to wjive the setback, you must initial the apprc:priate blank
below.) /
/I do not wish to waive:
i do wish to wrcive that selttack reCILIat;metit.
DESCRIP'I'IQN A -WO t DRANVING OF PROPOSVI) D1,; 'ELOPMENT:
(7o be filled in by individual proposing development)
f Q Jtge f doC 3-1 lq5
(Information for Property Owiwr AplOying
for Permit)
Mailing Address
i.'itylStatc/7.ip
n ,n -7-7t 141'A
----------------
(.Riparian Property Owner Information)
Signature
i �l '
ti rs��_. r �6 rV .
Print or Type Name
Q �t i r%Ca L n

t AdlbkI I I I I I I I a

plicant: e)'i"t 7 �� � f d.✓
5 f Permit #:
IQ: '
�/2///
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measuremer
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. F.
(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 fin
disturbance.
Excludes any
restoration and
temp impact
amount)
(^/
Dredge ❑ Fill ❑ Both ❑ Other
7
yy
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 0 Both ❑ Other ❑

} -Tic .�lewett
Auor Cl*n� Construction
w10-842-8 1 �eu/ett __-. _
1481 S n611
Supp9, aCc z�84 2S o 7 3135
Pay to the s 2y 66-112ie31
Order of /VC 11c,Z Date
$ ZOD.bd
i BRAN 1-I 00 BANK TRUST oomMPANY
AND Dollars 8
For
09 'G)
'; p 5 3 10112 ii;0005
11a 38 5
9 5B u•