56580D - Jordan

CAMA / ItbREDGE & FILL
iENERAL PERMIT Previous permit#
slew El Modification i (Complete Reissue -Partial Reissue Date previous permit issued
zed by the State of North Carolina, Department of Environment and Natural Resources l /; L
>astal Resour; es CorAnission in an area of environmental concern pursuant to 15A NCAC / lioU y �/� 1.2G
E9ftles attached.
Name STC t"c il! 7a1z'w Project Location: County /�flr+dS�✓ ��
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❑ CW DEW
D PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF
❑ IH ❑ UBA ❑ N/A
❑ PWS:
❑FC:
es / no PNA
yes / 60 ) Crit.Hab. yes / no
Street Address/ State Road/ Lot #(s)
Subdivision
City_ -�%: Ll70i✓ �Pf)r� ZIP--1?L�
Phone # ( ) River Basin 44,1,,�,�
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ig permit maybe required by: YoLd "." 1y PA[ !i ❑ See note on back regarding River Basin ru

AG
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue, Govemor James H. Gregson, Director Doe Freeman, Secretary
Date / 2- , & - Z D/y
Name of Property Owner Applying for Permit:
Nailing Address:
or7` Alill, SIC 9� j
I certify that I have authorized (agent)to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity). I zl-lq
at (my property located at)
/�P S
f �
This certification is valid thru (date)
Property Owner Signature
/2 . � - 2v/-: �J
n-6-

-eve II
,c
G7�
i £j
LP �k

017,04 Joel Klass 910-846-3360>} 704SB74870
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIFR/MOORING PILINGSIBOATLIFTIBOATHOUSE)
i
1 hereby certify that 1 own property adjacent to s
(Name uf. roperty Owner)
property located at
(Lot, Block, Road, etc.)
on _inN.i'.
�(Waterbody) (Town and/or County)
Applicant's phone #: Mailing Address: ' I 'r
He has described to me. as shown below, the development he is proposing at that location. and, 1
have no objections to his proposal. [ understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (15') from my a= 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
1 do wish to waive that setback requirement.
DESCRIPTION ANWOR DRAWING OF PROPOSED DE VELOPMEN'i:
(To befilled in by individual proposing development)
(Information for Property Owner Applying
for Permit)
Mailing Address?
(Riparian Property Owner Information)
>za �
ignature
City/State/7.ir Y Print or Typc Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to 4 s
(Name of: roperty Owner)
property located at i! ►'�`
on
(Waterbody)
Applicant's phone #•
1 (Lot, Block, Road, etc.)
in N.C.
(Town and/or County)
Mailing Address: ) J i'
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
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 (Riparian Property Owner Information)
for Permit)
r
Mailing Address r ignature
City/State ip r Print or Tvoe Name

117-04 Joel Klass 910-846-3360>> 7045874870
P:
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
. (FOR A PIEk MOORMG PILEVGS/BOA TLfFI/BOA THOUS'E)
I hereby certify that I own property adjacent to 's
{Name o!f perm, Q,oecr) .T
property located at
(Let, Block, Hood, etc.)
on in N.C.
(Waterbody) (Town and/or County)
Appikint's phone #:
t
Be has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. 1 understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (15') from my aru of riparian access unless
waived by tt►e. (If you wish to waive the setback, you mpat inldal the appropt-fatc blank
below.)
1 dgiqg wish to waive
( I do wish td waive that setback requirement,
USCRiPT>ION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be flHed in by individual proposing developovtl)
(information for Property Owner Applying (Riparian Property Owner Information) . .
for Permit)
Mau Tg Address '
,~ Signature
l ;
If lL

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIEJWOORING PI.LINGS/BoA TLIFTIBOATIIOUSE)
I hereby certify that 1 own property adjacent to s
(Name of P�Perty�Owner)
property located at 10 "1 6 HJ) {- Rd .
61 (Lot, Block, Road, etc.)
on in N.C.
(Waterbody) (Town And/or County)
Applicant's phone #: Mailing Address: A
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
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED .DEVELOPMENT:
(To be fUled in by indiv+dwal proposing developmwnt)
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
Mailing Address Signature

icant: S '4v67,✓ >v2C�J9>J
Permit#:
tribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id 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
impactamount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated Tina
disturbance.
Excludes any
restoration andh
temp impact
amount)
5
Dredge ❑ Fill ❑ Both ❑ Other
G S
J
L
Dredge ❑ Fill Both ❑ Other ❑
j-
Dredge ❑ Fill ❑ Both ❑ Other Vi
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 ❑

Post Office
U.S. Dollars and Cerds
zom
i600
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!� Amount
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NEUSSESSION�SEEREYG •
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