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(IsformatianfvrProperly OwnerAFp (R*amwProper[y0waerIaf0rmairou)
for Permig)
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Print or Type Name
Telephone Number
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I h=by GQdfy dW I owu prvperty adp=m to [i 222M 1 f]s •s
Q%unt of Property Owner)
pmpraty locaacd at 2Qta7 )TN S
(Lok Block Road, e6c.)
on Conagus n 6f;, - C>i-7 , N.C.
(Waterbody) (Town and/or CooW"
Appheamrs pboae # - + - 3 i Maims Adir+ c • WO MebL)Avial QI Z.
Pr=� JN C_ ;Q39
fk has deaeriibed to mc, as ahawa below►, the development Le is prvposiog at that location„ mod, I
havoc so objections to his proposal, i det M that a Pier/mooring Piliop / bodidl / boatbo®e
mmt be set bads a minium distance of fiftm fiact (155 fiom my arcs of 4mim access amens
waived by me. (If 7'an wM to wave tie sdbm* am =sat bridal the apprery iafe blank
_ below.)
1 49-ad wish to waive
I do wish to waive dud setbaA req iranart,
DFSC1tIlT" AIM OR DRAWING OF PROPOIM IWVE[.OPIrlcff..
(To JoYAW'a by oafeWdmdprapm ft
(Iaforncation for Property Owner APpl*g (Ripilmm Property Owner Informatiae)
for Permit)
Mailing Address s
P x . N(- Z79- 3
Gtyaaftaip Print or TMW RFM
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Vkba6 F =as*y. Gov mor Charies S. Jones, Director 1Viliiam G. Ross Jr„ Secretary
Authorized Agent Consent Agreement
'IAt'r, th►Czl C<s)!as—,jzcc-, Ie)&I is hereby a�ithorized to act on my behalf
(Parried Watme of Ageno
n order to obtain any CAMA permit(s) required tot the property listed below. The authorization is limited to the
specific activities described in the attached sketch,
.00ATION OF PROJECT:
aS 410,5
'ROPERTY OWNER MAILING ADDRESS:
R Wa r+rc-% L-4s�—b
- F4€ -I M-rt`o^
�e-r- 7-'7 5 P14ONE NO. 3iy- (G) L .(I131
UTHORIZED AGENT MAILING ADDRESS:
a�y+�
PHONE NO. 910-3a-)- 34-?
gnature of Property Owner
gnature of Authorized Agent: `

f

Division of Coastal N19t, Habitat Impact Computer Sheet
)licant: W O'yy:lW 4'k-
1p Permit #:
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd in your Habitat code sheet.
TOTAL Sq.-Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
)itat Name
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts
amount)
Dredge ❑ RIX Both ❑ Other ❑
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Dredge ❑ Fil Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other
ill Both ❑ Other ❑
Dredge ❑ Filly
2
7
Dredge ❑ Fill Both ❑ Other ❑
Dredge ❑ R4 Both ❑ Other ❑
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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 ❑
2 `fit) Gj--2�, Zo x 1 `-p

9023
Bankof America.
VTINORI CONSTRUCTION
ACH PIT 0&1=196
145 VIRGINIA LANE
SNEADS FERRY, NC 28460 66-19-530
[phone]
:Ram -An i /
DOLLARS ;
U
8
U-45
1180090230 1:0 5 3000 19611: 0006 SOS 2 1990,10
AUTHORIZED SIGNATURE