55841D - Chopus

hdAMA / 4REDGE & FILL
MNERAL PERMIT Previous permit # e
jNew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
-ized by thAtate of North Carolina, Department of Environment and Natural Resources
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC�} &/ 70 6
G;Rules attached
t Name 9
r7
0S—r dt Ct 3 Z'dl
o L R Ax State jL ZIP 73 yyy
(S 00) 2 7( - I/f, Fax # ( )
ed Agent 6 Piz A t C/ & o4y•e�
❑ CW CAE* ZP'PiC 0•ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑ FC:
PNA C ' Li b /
Project Location: County iG
Street Address/ State Road/ Lot #(s) /Sd /!�%Z
Subdivision
City/'ULalo.� 90,09c 1 ZIP 2? `//-� Z
Phone # ( )) River Basin L 4"iJ
7
Adj. Wtr. Body f zioa e �/L✓/r(nat
�
yes / io yes / no rit. a yes no Closest Maj. Wtr. Body ��L✓
Project/ Activity R A 1OL Al Q Z'- X , S?4 , n2f
(Scale:
ck)length
1(s)
ier(s)
ngth
nber
i iprap length /n2
distance offshore
x distance offshore
cannel
)ic yards
rip
se/ Boatlift
ulldozing
i
e Length 621
not sure yes no ; Z
s: not sure yes no
ium: n/a yes no P
yes
4ttached: yes no
ng permit maybe required by: /IULdPl, lP,4c-A ❑ See note on back regarding River Basin r

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent toj d�cjqtL is
(Name of Property Owner)
property located at 107 TI�� � u r , r �f&
(Lot, Block, Road, etc.)
�7
on _,-Jet- in ���Le .Lj� 4 el , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #:
Mailing 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.
-------------------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by property owner proposing development)
41. kt)
�pw r
5eLv.e I Ise v A-5 6) a tie
--------------------------------------------------------
(Information for Property Owner Applying
for Permit)
-------------------------------------------------------
(Riparian Property Owner Information)
Mailing Address
7n_ I ' . "15-7—. t :?2 Lhill
Signature

AWA
RCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Director
Dee Free
Secn
AGENT AUTHORIZATION FORM
Date: / <o
NVie of Property ner Applying for Permit: Name of Authorized Agent for this project:
Owner's Mailing Addrss:
Agent's Mailing Address: `
Phone Number ��� 7j Phone Number( t�)Z���
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)
Property Owner Sig tune Date

dicant: /J%� �j /t „ 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.
DISTURB TYPE
itat Name Choose One
jG2 p / L Dredge ❑ Fill Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other
COMPLETE•
■ Complete items 1, 2, and 3. Also complete
item 4 If Restricted Delivery Is d9dred.
■ Print your name and address on the reverse
so that we can return the card to you.
—f ■ Attach this card to the back of the mailpiece,
or on the front If space permits.
1. Article Addressed to:
Felix & Linda Zarzecki
148 Marlin Drive
Holden Beach, NC 28462
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated Tina
Disturbance total
disturbance.
Disturbance
disturbance.
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration andh
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts)
amount)
z
Z
a a
�00
a �gfiatu d
X ❑ Agent
❑ Addressee
B. eceived Prf Date of Del�ry
v
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
1
<t9m
3.
Service type
ertifled Mall mail Return Receipt for Merchandise
❑ Insured Mall ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) p yes
2. Article Number
(Trans rfrommWoelab 7010 0780 0002 0184 4552
PS Form 3811, February 2004 Domestic Return Receipt 102595-024A-1640
■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
A. Signature
X�� Agent
Addre
B. Received by (Printed Name) C. Date of Qel
1. Article Addressed to:
I D. Is delivery address different from item 1 ?F ❑ lfe:
If YES, enter delivery address below: ❑ No

JANIE BRITT BROWN
GERALD L BROWN PH. 910-842-5685
510 RUFFIN LN
SUPPLY, NC 28462
4053101120:00052L442963400275L
H.ft. CU..
2751
66-112/531