57569D - Metcalfe

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HOERR
North Carolina Depatrient of Env4ronment aid Natural Resources
Division of.0 Manapmerd .
9evedy Eaves Perdue James H. GmWn Dee Freeman
GoveM7 t3 rotor ISwe+vary
AGENT AUTHORIZATION FORM
Name of Property owner Applying for Pennit: Name of Authorized Agent for this project:
.R -� '11-�?3�'�n.�dsQr�
Owner's hbl&gAddress:
Phone Number
,agent's Maffing Adoress:
Phone f,,!L ber 1 LPZ=(5315
l certify that i have authorized the agent listed above, to act on my behalf, for the purpose of applying
and obtaining all CAMIA Permita necessary to instals or construct the following �activtty):
(my property located) at
Trtis cartltication is valid thru (date) g, )1
NI
Property Owner SigtIture Date

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ADJACENT RMARUN- PROPERTY OA4NMRSTATEIMEINI
Z- g t pay 0A( D71T /may ,I77 tom• T[. !L♦ L. { '� �4 C'li i'! D! ERl TlV✓.W..�CT ! ! y.t ,tIVJ�lJ�7 ! LI! J i�[.�� j ja LIl•�r / V
herrbp c•rS;y that i oven praxrsy
('San-.e of Propkrty Owner)
perry iocoted at • ` i _, ��� __
(Lot, L O&, Road, etc.}
Ir t ) �
(Waterbody) (Towit ndfor Cortnty)
AppiitaGt'tt pkoRt'3: �/L ��(r:?Y��� Ziai:iva;A.3d-rss:�1.�Kr�illli'r5+ �1l��:►1
Re has described to me, as shover; `:xl rw, :bc dcvctcj:,rr,t is proposartuat &mCocatio-i a.-4 i
have no obj=ict>~ to his propc3ol. I t+ut;cestand that a pics/.^ awing pi Imp t boat}itt i boath,4ae
mu,g be }et hwk a atinirrm -n distance oi` fttie.rt feet 051 n`riparian 5c::.esh umlr- ,
xWvsd by mc. (jr you wish to waive the whack, you must ieitia} be appropriate biaalt
below. j
I go Slat wish to waic'e
.� . [ do wis}t to waive tia.sa;;aacii :equireiiettt.
OVSCI WHON AN—DIOR I)itAM M OF PROPOSED DFVELOPMEN"i
(To be filled in by indi.4daal prai!rsin; dcvelopmen,)
r
(Information for Property OvrntsApply rg
for Permit:)
Wtai il^.cl A ddrez
Ciry.S:atvzip
(Riparian Vrt -nnr Iion) -
5�tt?ei�rc
P"irt or .r —}C Name
-s 1
Zl.titilusrr ?fie:-r{vr
ionc Number

ADJACENT RIPARLALN PROPERTY OWNER STATEMENT
(FOR A PIEAIMOORING PILINGSBOATLIFTBOATEOUSE)
I hereby certify that I own property adjacent toCIv) rips 9 R)L44 ge' I [ IA, 's
(Name of Propkrty Owner)
property located at i 6&rc, sh �r
(Lot, Block, Road, etc.)
on a n p ! . , in N.C.
(Waterbody) (Town and/or County) ��,11
Applicant's phone #:g�p7'63� Mailing Address: 6Z45 bzZneiS Nr -�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 beset back a minimum distance of fifteen feet (15D from ea of riparian access unless
waived by me. (If you wish to waive the setback, you mus initial he 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)
6 C-�C, 1,0j" rjq .0,
v
(Information for Property Owner Applying
for Permit)
EM- a e, 6
Mailing Address
a>oIze)L. Sc c2uyu
City/State/Zip
(Riparian Property Owner Information)
r I111L Vl 1 VYG l-liilM

Owners: Charles and Robyn Metcalfe
120 Starfish Dr Holden Beach NC 28462
803- 499- 4469
Contractor: Richardson Construction
3235 Seacrest Ave SW Supply NC
910-367-0335
34ft total distance from bulkhead
existing
8x20 float
Proposed
12ftx12ft
boat lift
26'
existing pier and ramp
120 St
20ft ramp 450ft Ic
- - - - ftx10ft pier

WIN Wi
111111 IIIIIIillll IIIII Ili IIIII IIIIII lilll'
,� II

C Division of Coastal Mgt. Habitat Impact Computer Sheet
Permit #:
te:
V-221t I
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd in your Habitat code sheet.
kat 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 ❑ 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 ❑

WILLIE CLARENCE RICHARDSON
DBA RICHARDSON CONSTRUCTION
PH.910-842-5596
3235 SEACREST AVE SW
SUPPLY, NC 28462-2589
Pay to the --21
Order of �! n
�/ Q-/%
Date
BRANCH
BA NQ AND TRUSTCOMPANY
1-0-BANK BUT BBT.ccmirQ�fQAk��
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Fo- - -
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