57378D - Taggart

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• NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson Dee Freei
Governor Director Secre
AGENT AUTHORIZATION FORM
Date: ` — //
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
Owner's Mailing Address:
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5 ;-tg 20 0
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Phone Number (9%). ,19 200 0
Agent's Mailing Address:
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Phone Number (910) Z3o6
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)
HIM
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Prop rty Owner Signature
Date

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DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify, that I own property adjacent to JPd� eS is
(Name of ProperfY Owner)property located at � � �/� ,�i��sv�v ,7,�y� ,
(Lot, Block, Road, etc.)
onSoWk5 CN e in72)e3,r1 /3 e ?N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: q 10 620 2- 1 Mailing Address: fro '64)X 35�32
e" MA-dur-t✓ 7�VSAz 9J4<Ar tic
He/She has described to me as shown below the development he/she is proposing at that location,
and I have no objections to the proposal.
-----------------------------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(Individual proposing development must fill in description below or attach a site drawing)
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in writi
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext. Wilmington, NC
DCM representatives can also be contacted at [phone].
No resnon.se is considered the same as no ohiection if you have been notified by Certified Mail
(Property Owner Information)
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Signature /f
Print or Type Name
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n Pro
Signature Print or Type "Name
Mailing Address
Mailing Address

:)licant:
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Permit #: � 737,�S-
Scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
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 final
disturbance.
Excludes any
restoration and/o
temp impact
amount)
i W
Dredge ❑ Fill ❑ Both ❑ Other ❑
/ �/�
/���
T S
Dredge ❑ Fill 05 Both ❑ Other
37.E 46
3 % S
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 ❑

ID Division of Coastal &19t, Habitat Impact Computer Sheet
)plicant: � 1 /y � Permit #
ate:
a� (I
9�-3 Tq t)
ascribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
and in your Habitat code sheet.
bitat 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
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
l t
(amount)
O t
Dredge ❑ Fill�j Both ❑ Other ❑
o
Dredge ❑ Fill Both ❑ Other ❑
aS
Dredge ❑ Fill Both ❑ Otherw
S
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 ❑

DELTA DOCK & BOAT LIFT
PO BOX 3532
TOSAIL BEACH, NC 28445
"
First Citizens
Bank
8333
DATE
13 /1 66-30/531
365
DOLLARS
citizens.com
AoP
33311' l:053L00300l:00353L99L5041I

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