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(Scale: 1 i /
CAMA / DREDGE & FILL 5
GENERAL PERMIT Previous permit #
l',lew - Modification . Complete Reissue ❑Partial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources '
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC W�
*—!" /( Rules attached.
nt Name i 1wVVJQS L a H C i I Project Location: County pe%�'V" l 0.
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s < Street Address/ State Road/ Lot #(s)
StateN.(C ZIPn-
# ( ) q Fax # ( ) Subdivision
ized Agent AA, pi myf<'
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C_ OEA HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑FC:
yes P no PNA yes rno) Crit.Hab. yes / no
of Project/ Activity
lock) length X
"m(s)
pier(s)
length
camber
gad/ Riprap length
ivg distance offshore
nax distance offshore
channel
ubic yards
amp
)use/ Boatlift
ine Length - L- -K-)
not sure yes t
:gs: not sure yes
>rium: n/a yes no
ling permit may be required by: 141'kA ( K Ot. ❑ See note on back regarding River Basin
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28/2010 14:37 9197790826
TRYON BUSINESS CTR
PAGE 02
28 10 01:50P mark Clements 910-270-9110
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FORA PIERIMOOATING PILINGSIBOATLIFTYBOATUOUSE)
I hereby certify that I. own propel' adjacent to I is
(Name of Property Owbex)
properly located at !) 3 _
(Ut, Block, Road, etc.)
on�'Vl ►�JQ �113� N koiCJ r�c�e1� , N.C.
(Waterbody) (Tome an. /OT COQMty)
He has described to me, as shown below, the development he is proposing at that location,
and, l have co objections to his proposal. I understand that a pia/mooring pilings/boatlifl/boathouse
must be set back a winimurn distance of fifteen feet (15') froru my area of riparian access unless
waived by me.
I do not wish to waive the setback requirement.
-fA",h
do wish to waive that setback requirement.��----w---_------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be felled in by individual proposing developnerrt)
i V iA-A A-- T--!-! T--T-T!-n - -------
S'
Print or Typc Name
Telephone Number.

a-Lrazeg 1 c SystemsUSA I nc
2e 10 02:16p mark Clements Ulu
-ciu-asiv
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIF.RIMOORING PILINGSIBOATLIFTIBOATHOIISE)
r' 1
I hereby certify that I own property adjacent to - - -S r ail('v( s
(Name of Property Owner)
property located at ! 1 3 L; L,
/ (Lot, Block, Road, etc.) t's
on �Yl l i�,�in M�d)
,N.C.
(Waterbotly) (sa or Cw
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 pierlmooringpilings/boatliftAwathouse
must be set back a minimum distance of fifteen feet 051 from my area of riparian access unless
waived by me.
1 do not wish to waive the setback requirement.
1 do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
�2 G
Si tore — - - - — --- -
X Print or Type Name
Telephone Number
%( Date: 7
P_C

Letter of agent
have retained Mark Clements DBA, Clements
Marine Construction Inc, to make plication 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.
P�
Signature
��k1le-`4 ~� (date t
Contact information

IC Division of Coastal Mgt. Habitat Impact Computer Sheet
ppltcant: Permit
ate:
escribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
)und in your Habitat code sheet.
abitat 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 fina
disturbance.
Excludes any
restoration and/c
temp impact
amount
OW
Dredge ❑ Fill ❑ Both ❑ Other
49
y"61
b�
Dredge ❑ Fill ❑ Both ❑ Other
H4
1+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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
So = 2-40

mom
CLEMENTS MARINE CONSTRUCTION INC ® 2039
112 CIRCLE DRIVE 910-270-9110
HAMPSTEAD, NC 28443
r 66-30i531
365
�� Date
----- _ Dol rs
First Citizens
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first t� bk ns.com 10 J� t vWE
FOY
1:0 S 3 100 3001:0 3 S 3 20EI L L. S13oo 02039
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