56627D - Hampton

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson Dee Freem
3overnor
Director Secret`
AGENT AUTHORIZATION FORM
Date:
Jame of Property Owne Applying for Permit: Name of Authorized Agent for this project:
Jed Y •4'�'1770iV J 4," le-- J o/j'�S
)wner's Mailing Addre, :
f 3
Phone Number (%/Is) 3� %�b�Z> 9
GCGC y63 - 207—SiSI
Agent's Mailing Address:
Phone Number( 1
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
(my property located) at
This certification is valid
-,� 0 b D r i'�iN; LOv
(date)
Pyol(ert4 Owner Signature
` lz_/
YJ
Date
G Z 71

ADJACENT RIPARIAN PROPERTY OWNER STATENENT
(FOR A PIERW00RI;YG PILLVG,s/BOATLJ , 0.4 THOUSE)
I hereby certify that I oun property adjacent to -le t? ' V L p�
zo i located 2zt�._�t.0 ne of l) operty Owner)
ry
Oil �� .. in —edA � 7'E�
aterbod -T ---- r - , N.C.
y) (Town a( d/or County)
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 ripariann 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
I do wish to waive that setback requirement.
----------------------------------------- --------------------- -----------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPM IN-T:
(To be filled in by individual proposing development)
If you bave objections to what is being proposed, you must notify the Division Of Coastal Mana ement C
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal snagDriye tnel wYiDtCM) i ;��ng
DCIYI representatives can also be contacted at [phone].Ext.
o re
4PonseSt considered the same as no obfeclton If you have been notified by Certified Mail
(Information for Property Owner/Applicant Applying for permit) (Ripari Pr rty Owner Information)
N ailing Address 7
Signature
Cityistate/Zip $ �&0_,—%VC 'j
/ t---- /? Print or
C vg/l> - � / - 06 0 "IYpe Name
911
T 1 phone Numbe - p P
Telephone Number
�b3- (a-35 3(c_
127 Cardinal Dnve Ext., Wilmington, Ncrth CaroMa 28405•3845
Phone: [phone] FAX- 911-19s.uad t,

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIEBJIIOGRIVG PILIA'GSIBO_4TLIFT,B0.4THOUSE)
I hereby- certify that I own property adi acent to
r, A -r , O1ape of Property Owner)
property located at
N WC n le
He has described to me, as shown below, the development he is proposing at that location, and, I hw
no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse must be;
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
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
z
x0•
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Est. Wilmington
DCM representatives can also be contacted at [phone].
No response is considered the same as no ob'ec:ion if you have bean notified by Certified Mail
(Information for Proper q Owner/Applicant
Applyil!g fwr it)
qkz
CL
City/State-Mn. 1-1-n I A �.�y-- -U.Aft' _ V vv
(Riparian Property Owner Information)
� 1
Sio at
�_ kCA. E Gad

C Division of Coastal N19t, Habitat Impact Computer Sleet
n
plicant: Permit #:
te: I
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
ind in your Habitat code sheet.
bitat 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
r7
lJ/'� -
�js�
V V
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 ❑
�n — 2/ t / -7 x (n ; -?Cz% 114 , - 1

JAMES W. JONES, JR ; "'` 66-85/531 3097
,DONNA M. JONES
y: 4522 DEAN DR. PH. 910-3954999 § ,,
WILMINGTON, NC 28405 ;s
oe
RBC Bankm
R BC Runk R,s n)
�iAr
I:0S31008S0I:027642S819ll' 3097
wvv oo.;s:i�,nrmuk oiwnwo w�nu»vnc. i-crw":anrWNIANC