57309D - Mylroie

,CAMA / DREDGE & FILL
3ENERAL PERMIT Previous permit#
�Igevv ' ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources Z/� �/2
-oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC Q l/
1wwes attached.
t Name r' ,Zq �/-� yL Project Location: County
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yes / no PNA yes /(no Crit.Hab. yes / no >
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ling permit may be required by: su/r Se / IF6,0C4 ❑ See note on back regarding River Basin i
A2 , � � s it .. /J a n�A� e_/ -. Gn - /n-! _ - -J I / /

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
verly Eaves Perdue James H. Gregson
Director
ivernor
Dee Freema
Secretar
AGENT AUTHORIZATION FORM
Date: AP91 2C
me of Property Owner Applying for Permit. Name of Authorized Agent for this project.
vner's Mailing Address:
hone Number (��% a !�2Z.2.
Agent's Mailing Address:
Phone Number'���
9lo g-&-o !a
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
x and obtaining all CAMA Permits necessary to install or construct the following (activity):
;my property located) at
This certification is valid thru (date)
4& tL
14 Prnm-rtv 0 ner Signature Date

CA) u u [!t-
0', 64
4
T
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A

f,J,6 bY._x_7 t/ U ,
:'ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOIL A pTEIUMOORirIG 'IL.iNmBOATLIFTBOAT'HOUSE)
I hereby certify that I own property adjacent to 6 U — 4-VA'-
(Name of Property Ors ner)
property located atCI h�fi�CJ: �iG �E�1,�.
(Lot, Block, Road, etc.)
on .C.
in
(Waterbody) (Town and/or County)
Applicant's phone #:� 4-CMailing Addre:ss:__-_�'f� — _
He has described to me, as shown below, the development he is proposing at that location, and,1
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift I boathouse
must be set back a minimum distance of fifteen feet (151) from my area of riparian access unless
waived by me. (if you wish to waive the setback, you must initial the appropriate blank
below.)
1 do not wish to waive
1 do wish to waive that setback requirement.
-----------------------------------
--------- DE,'_+C;ICIPTION AND/OR DRAWING: OF PROPOSED DEVELOPMENT:
(To he filled in by individual proposing development)
(Wormation r(Ir pl-operty Owner Applying
for Permit)
Mailing Address
Citvl�ta2e/7.i�
(Riparian Property Owner Information) I
Signatur...
Prin or Type blame

ADJACENT RIPARIAN p O R�OLSTATEMENT
(FOR A PIER/MNGNOAT�FTBOATHOUS
. �zs
I hereby certify that I own property adjacent to s7
(Name of Property caner)
property located at
(Lot, Block, Road, etc.)
in S�yn S' , N.C.
on
(Waterbody) (Town and/or County)
Applicant's phone f6.1 -� � wiling Address:
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 (IS') 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.
----------
G OF PROPOSED DEVELOPMENT:
DESCRIPTION AND/OR DRAWIN
(To be rlled in by individual proposing development)
- ------------------------
(Information for Property Owner Applying (Riparian Property O-ner Information)
for Permit)
y �S
�CZ> Signature
Mailing Address
/ / ,- / i /, 1 /9 o 1 / .O%/V /%O A tcl /C) o f? id �i

plicant:
L Permit #: S %d 9
te:
544
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measuremer
ind in your Habitat code sheet.
TOTAL Sq. Ft. FINAL Sq. Ft.
(Applied for. (Anticipated final
DISTURB TYPE Disturbance total disturbance.
�itat Name Choose One includes any Excludes any
anticipated restoration
restoration or and/or temp
temp impacts) 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)
_ /
�W
Dredge ❑ Fill ❑ Both ❑ Other
C,�
/
(/ (
3 7 J
Dredge ❑ Fill ❑ Both ❑ Other f�
2
20V
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 ❑
� � X� 1 �Gq

ROGER K MILLIMAN 6
PH. [phone] 66 tt2 /53t
9
1118 HIDDEN WAY SW /
CALABASH, NC 28467-2955
W A/,
BRANCH BANKING AND TRUST COMPANYG 3jr oq
1-800-BANK 88T SOT-COM 11 ww.�JJ (1'�
( J�
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