57525D - McGoogan

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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Michael F. Easley, Governor Charles S. Jones, Director
Authorized Agent Consent Agreement
Wfliam G. Ross Jr., Secretai
---_--Abli ►+try k 1 is hereby authorized to act on my behalf
(Printed Name of Agent)
order to obtain any CAMA permit(s) required for the property listed below. The authorization is limited to the
ecific activities described in the attached sketch.
)CATION OF PROJECT:
3Czr,'G 3 IT
<U LL-'�`r
:OPERTY OWNER MAILING ADDRESS:
)8 )1i1/G 1-OnI A� L
PHONE NO. 3.�j4,-,�1-iJ�L3
THORIZED AGENT MAILING ADDRESS:
PHONE NO. 9 )D- 3y,S"
nature of Property Owner.
nature of Authorized Agent. ��(/

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILWGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to c flszi,15cyy-At•1 Is
(Name of Property Owner)
property located at _ 3ctSA 3 to S 7.
(Lot, Block, Road, etc.)
on C 4NA ltji in _ �12== C:CT`r' , N.C.
(Waterbody) (Town and/or County)
Applicant's phone t 78V Mailing Address: yjb tc i 1_ N vJ
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.)
x 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 Info tion)
for Permit)
Mailing Address Signature
City/State/Zip Print or Type Name

Mailing
City/Stat wZip
ADJACENT..RIPARIAN PROPERTY:.OVVNER_gTATEMENT
(FOR:! PR�MOORtNG Pl]:WGBOA.TIIFTBDe1 TR`OIISB)
I hareby cex* *at:I oMvti property adjacent to cjAml.IES �1 � Af•1 's
(Name of Property Owner)
propeaty_locaied at 30t�4 .. 31in S'�i
(Lot; Bkx*, Road, etc.)
dn.-- CA u At m. , N:C.
(Waterbody) -(Town and/or County)
Apphesufs phone# aI. I -� . a .. Mx1liag.Ad4ress: `VJbjJ�JAjt HArYI gjp,-
e has described do ..
tne, as shown below, the developmentlye is proposing at:tiiat location, and, I
have no objections to his:proposal. I understand that a pierhnooringpilings / boatlifft / boathouse
must beset back a minims disfencc arff'db" feet l3 -�'r" -..
area of ripeciaa access unless
waived by me. (If you wktr to waive the setback, you must initial the_:apprepriate. blank
below.)
H
I do not wish to waive
\Nt
x . "il • .4. I dg wish to waive that setback requirement.
DES+CRRIP HONAN'D/OR DRAWING OF PROPOSED DEVEI.0p11iiENTc
(l`o 0 obit ndhidaal proposbw r>nviopmenr)
(Infot�reation foc�ti . i-
for Peroiit) Owner APPS. {. erty .. 9 PropOwner Information)
s
Print orType Nacre
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ilicant: 6' 4wee<
e: / -;/IL7—/ll
F pv� oIA
Permit #: 5752 S
cribe 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
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 ❑
Dredge ❑ Fill ❑ Both ❑ Ot
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 ❑

NTINORI CONSTRUCTION
145 VIRGINIA LANE
SNEADS FERRY, NC 28460
[phone]
Ncn'i�NAP
,T-
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Bank of America
ACH RIT053000196
66-19-530
116 0094 2311' g053000 1961: 000650S 2 L99011'
9423
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AUTHO ED SIGN RE
6 co I M
DOLLARS
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