54565D Clancy

CAMA / L�i DREDGE & FILL
xENERAL PERMIT
NeW ❑Modification ❑Complete Reissue ❑Partial Reissue
Previous permit #
Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC �,_
® Rules attached.
C Name`%Orw 1 +� _T_— Project Location: County P.wt ✓
's I Street Address/ State Road/ Lot #(s)
1 < State INC, ZIP �;Ajy .k ` '
Fax # ( ) Subdivision �iAaskAnG n * ty,,,(-�,
ed Agent }(,t V� L I bliblis ity ntie ZIP 64uk
1
❑ CW [IEW ❑ PTA XES ❑ PTS one # l ,q r (b ) WO - -�9 C S River Basin
❑ OEA ❑ HHF ElIH ❑ UBA ❑ N/A Adj. Wtr. Body A I' cwl- I L (nat r
❑ PWS: ❑ FC: A A VJ ' ._
,��') Closest Maj. Wtr. BodyAi W
es J no PNA yes / C2✓ Crit.Hab. yes / no
F Project/ Activity I
(Scale: I
Attached: yes no
Ping permit may be required by: 'P4�d� ✓ w ❑ See note on back regarding River Basin i
1 1 1 1. I _ i r f I , 1 _ r _ _ . .I % . 1 . - 1 . _ , . 1 —L - . i / j_

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Letter of agent
I have retained Mark Clements DBA, Clements
Marine Construction Inc, to makeypplication for any and all permits needed to start
construction on the work requested for our property or properties.
By allowing Mr. Clements to make such applications I do understand that this will in no
way relieve me of any obligations to perform all work according to the building codes of
North Carolina, CAMA, DWQ or any other state and or county ordinances.
IT�'Q XA-d 44-
Print
Signature�A kk-7 -, ndate
Contact information

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to j C2 tnfl5 "11 C v1 's
(Name of Property Owner)
property located at �� 3 ��q� ,�A
(Lot, Block, Road, etc.)
on �l, ,in der—' N.C.
(Waterbody) (Town and/or C nty)
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
�J r (To be filled in by individualproposing development)
�-✓� 1�r ,Dry �.
Signature
XPrint or Type Name

( I U/ -/UI V 11 ;Ili 'JI'J ( tJUbZb 1KYLPN t=INtbb WK rlAt3t uz
14 10 02:58p mark Clements 910-270-9110 P-2
ADJACENT RIpApJAN PROPERTY OWNER STATEMENT
I hereby certify that I 0w13 property adjacent to 1 S
(Nome of Property Owner)
property located at
(Lot, Bk)ck, Road, etc.)
on rar N.C.
(Waterbody) (Town a"11 r Cuinty)
He has described to me as Shown below, the development be is proposing at that location,
and, I have no objections to his proposal.
DESCR1PTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filled in by iR9ffvidu91PP0P#s09 dewdOPmefft)
K,
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Signture
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Print or Type Nam
TUepfionc Niinl5er

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Division of Coastal Mgt. Habitat Impact Computer Sheet
>licant. 1 �n �-I�OI.�C,c Permit #:
e:
>cribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
nd 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/c
temp impact
amount
s
J
Dredge ❑ Fill Both ❑ Other ❑
v 1
I a"6
Dredge El Fill [I Both ❑ Other
`� U
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 ❑

ItcrNA* Mom mom amm
CLEMENTS MARINE CONSTRUCTION INC ® 1997
112 CIRCLE DRNE 910-270-9110
HAMPSTEAD, NC 28U3 66-30/53 i
10` le— i o 365
(l 1 Date
a to for he (� e $ 400 ^
['7t �r Dollars it
B.ck.
First Citizens
Bank���
(irstciUzens.com �
Im
For
i:0 S 3 L00 3001:0 3 S 3 208 L4 SEIV O L 99 7
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