56662D - Lewis

CAMA / DREDGE & FILL
xENERAL PERMIT
New JModification ❑Complete Reissue ❑Partial Reissue
Previous permit #
Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources
oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC //! 1 2 G D
lye, Rwles attached.
Name )/' �/ 1 ✓/S Project Location: County L' U & s c,i /e,ll�
-20 07,7 �- _ , .- i A d , Street Address/ State Road/ Lot #(s) 2 06 i ;y/; /
U It M _ State_ `: ILZIP 2
( /D)�2'161- WOZ Fax #
Agent
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❑ OEA ❑ HHF ❑ IH L UBA ❑ N/A
❑ PWS: ❑ FC:
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Subdivision 5'4/-� /�,.Z e ter
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g permit may be required by: Xe44,-'-5 GitC.0 e4ou N?l,. ❑ See note on back regarding River Basin ru

03/10/2011 13:52 9106714037 SHAW OFFICE SUPPLIES
ar 10 1' 11Vp 1Q1084V708 842470S
PAGE 01
P,2
ADJ'ACE.NT RLPA1• AN PROPERTY OWNER STATEMENT
(TIOR A Pl r:.N/.'1 002-1NG PJUNGS1B0ATr_ F, TIBOATHOUsE)
I hereby cei- dfy that I oNvn property adjacent to
c) //(Name of Property Owner)
rrope.ty located az�20Le l5 G e-E 04na ';f v
(Lot, Block, Road, etc:.)
(Waterbody) ^� ((Tb�n.• andlor County
Applicant's phone #: IO'7 7 Mailing Addres.sZLZA._ SCX(�C�N. d .
Iic has de;c*ibed to me, as shown brow, the development he is proposin; at that location, ard, I
have no ob eciionstr his proposal. I understandllatzgierimecring pilings /boadift! boathouse
nnv-t be setback a minimum distance of fifteen feet 03)'from iny area of riraririn access unless
Waived by n1r.. (If you wish to waive the setback, you must initial the appropriate blank
below.)
_ l dodo not wish to waive
✓ J. do wish to waive that sett: ack rcq%drernent.
__-------------------- -- - ----_- _-------
DESCRTPTION AND!OR DIQA�)gNG OF 1>ROF0UD DEVELOFMINT:--• - - -
(To he frl,►.ed hV by ir2dividua1 pro osing dne; ment)
IS
�; � .lam �
►�,1� o
_----~----- — ---••..............•--------------------------------- -- -----------_---_--- --�
(Information for)Properi)• Owner Applying. (Riparian Property ©wnerJ'a ' Motion)
for kermitj
Vial; l!ng Address n / Sigra:ure
�11r ta;e.�Zip " L C � %
Print cr Type Name

tar 10 11 12:44p
Mar 10 11 12:27p - 19,108424798 ---- -- -- — — --- - - 8424798 ----- — p 2 --
h L-,�-e� �CJi ✓C�
ADJACENT RIPARLA-I PROPERTY OWNER STATEMENT
(FOR A PIERIMOORINO PI fNGS/B OATL.IFTBOATHOUSE)
I he-eby ccrtify that Iowa property -adjacent to Dglj /_ Ec;,17'.f 's
(Name of Property Owner) � (�
property located a;
e
(Lot, Block, Road, eta)
J on _ �'- , in Gc cC/ �; 4)
(Waterbody) —' A
own and/or County)
Applicant's phone #: 73j` G-d- I aUWng Address: /,-f 'Ji'>`G ,��^•�� .Kl'/
9/D- z ;�31
He has described to me, as shown below, tho development he: is proposing at that location, and, I
have no objections to his proposal I understand that a pier/mooring pilings / boartift / boa.thouse
must beset back a miniraurn distance off iftcen 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 Dot wish to waive
✓_ I do wish to waive that setback requirement.
....... _------.............. ----------......_----— ----------
DESCRIPTION AND/OR DRAWING OP PROPOSED DEVELOPMENT:
(To be fflied in by'individ ruposrxg dtvtlop�nent)
e o • 3�
k
v5 a
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
Mailing Address Signature
py"'S tatc/Zip Print or Type Name
Tt I- lone N I 1 bci I I - _ Telephone Number

i
h
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson Dee FreE
Governor Director Secr
AGENT AUTHORIZATION FORM
Date: '3-1 d - I
Jame of Property Owner Applying for Permit:
DA IT I el) 11 5. -
)wner's Mailing Address:
'hone Number IG
Name of Authorized Agent for this project:
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 thru (date)

c It a C) FT
1a. ` T

plicant: /�� L ��✓, s
Permit#: 5-4 /�r2 -/3�
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. 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 fin
disturbance.
Excludes any
restoration and
temp impact
amount)
/
Dv/",,
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 ❑

DAN LEWIS
SHEILA W LEWIS 7680
2087 BETHESDA CHURCH RD 88 172/531
ORRUM, NC 28369
BRANCN BANKING AND TRUST COMPANY 1pq�
1.800-BANK 88T Bw.com y�
l:0531011211:000S I i743463111'0
p Melibq Gerk.
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