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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
Dee Freen
Secrel
AGENT AUTHORIZATION FORM
Date:
Jame of Property Owner Applying for Permit: Name of Authorized Agent for this project:
hQryf'C1
Dwner's Mailing Address:
9FS v of r �k✓
Agent's Mailing Address:
%�an S-h4`fi t-oe
�F Y72�
'hone Number (q I L)) 2R7=y q 5"S _ Phone Number (9/ D `iZ
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):
A;der ban �ro !�%E r fL �d101K,� o ` OT
r
iy% rri s 5,2�-fie r v
T �I
(my property located) at SY R_ /z`Or /j/k/ SZ yZ0
G.S weeA ed +" C
This certification is valid thru (date)
Property Owner Signature Date

J6 6>ti-1-7V�
X
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORINGPILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to 7no r y► S le 16, r y -'s
(Name of Prope Owner)
property located at 9 $
(Lot, Bock, Road, etc.)
on YVacCce4 M A ,,,i i ve Y- , in Ci 5 �n z S-ql O ,L (,&MHsJAI id e,1,), N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: q10 - 04gq Mailing Address: 7 ff PlOti Sfh ylePil-Y
tCA Yl- v,'%lC' Ile-2 b° Y7 z
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.)
6' ).T. I do not wish to waive
I do wish to waive that setback requirement.
-------- -------- ------------------------ 7------- -----7--------------------------------------- 7-7---------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
-------------------------------------------------------------------------------------------------------------------
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
Mailing Address V�— Signature
L Va r v lal Tr IAO- - -

Zoovew
Tyson.
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to ^%a ry /W 91 / ►'1, 's
(Name of Property caner)
property located at Cl" � .5- >ve-s 4 R}� ,fir
(Lot, Block, Road, etc.)
on a C C A w, U �,✓ R i )� Pn , in Q. s h , C U dY , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: Q 10 ` a 97- gVSYMailing Address: 9 s's Wiyerp,, l/r I1r. - 1
Gs4, tie I;-ne
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal.
---------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by property owner proposing development)
--------------------------------------------------------
(Information for Property Owner Applying
for Permit)
2.��5-q fi,'VV-v'5n1e
Mailing Address
n. , l e //n
--------------------------------------------------------
(Riparian Property Owner Information)
Signature

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORIIYGPHJNGSfBOA.TiITT/BOATHOIISE)
I hereby certify that I own property adjacent to 0' Irrl S S,' H /EfAriis
(Name of PropertyOwner)
property located at _ q U 91 ►1 Q AI W a.4 /l/C j & y 2
(Lo , Block, Road, etc.)
on W&,ccay.,cAw, Q',yEr , in a, N l e ruh5 &--, ik N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: %10- by1-,31'18 Mailing Address: 71.,V 40011
". 10-Ale if/C 3 y7 Z
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 / boatliH / boathouse
must be set back a minimum distance of fifteen feet (I5D 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
�_s&I do wisli to waive that setback requirement.
...
DESCRIPTION AND/OR DRAWING OE PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
(see
CPi e,r
aid -j
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
7�r,111o,sh�le4,-
Mailing Address Signature

: Division of Coastal Mgt. Habitat Impact Computer Sheet
dicant: / "l tm S �} +a,v'
3. Y
Permit #:
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 [I Other ❑9—
Dredge ❑ Fill Both El Other ❑
' a
- -
d��
Dredge ❑ Fill Both ❑ Other ❑
W
Dredge ❑ Fill ❑ Both ❑ Other
L4.4
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 ❑

MORRIS L. SINGLETARY NCDL 722221
AMY F. SINGLETARY NCDL 3048287
PH.910-642-0684 -L C r
795 ALTON SINGLETARY RD.( AID)(05J� BPS • —9 / l
WHITEVILLE, NC 28472
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State Employees' Credit Union
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1:253177049i:0863082 0311 L520 - ---