54428D - Ellis

- CAMA / DREDGE & FILL
3"E N E RAL PERMIT Previous permit #
iNew _ :ModiQcation . ❑Complete Reissue ❑Partial Reissue Date previous permit issued
sized by the State of North Carolina, Department of Environment and Natural Resources J/
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC 2/" . /ZQ G
C9-Rules attached.
it �
Name - d- C�` L LjS Project Location: County lj J iv
Street Address/ State Road/ Lot #(s) Lp i / y
State N ZIPG Z�3
6 (" 62/1�j-63Y3 Fax # ( )
,ed Agent J e(,t%p {�n
CW HEW ❑ PIA-- Et; 5 ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑FC:
yes / no PNA ye no ` Crit.Hab. yes / no
f Project/ Activity
lock) length X �" i
rm(s) / 7` ix 0 ��o✓Ot�
pier(s)
length
number
ead/ Riprap length
ivg distance offshore
-nax distance offshore
channel
:ubic yards
amp
ousB� oatlift- —2 1) /Z
Bulldozing g
ine Length / —7 //
not sure yes
igs: not sure yes
Vi
nrium: n/a yes
t�!
>• yes
X
r Attached: -'Yes,)
no
Subdivision �'G"N/„�s-
yG,2
City F
4 � 1SZ"Zw ZIP
Phone # ( ) River Basin L1--/19
i
Adj. Wtr. Body �r l /�/!yt�/ (nat.
Closest Maj. Wtr. Body / w�
P�/,44
(Scale:
ling permit may be required by: �� P /I i./ �SGaG ; �J� G lj El see note o b ck regardin i�
. C---:_I -- a:.:,,.,, (`TOc/iTi.—�. J -- - ...Je
Basin

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rpox.

2/13/2010 13:50
9105798979
ERNEST G CREWS CONST
PAGE 01/01
Beverly (saves perdue
Governor
-Date, X-
AKIfAa
HCDEWR
Notch Carolina Department of Environment and Natural Resources
Division of Coastal Management
James H. Gregson
Director
6gENT AUTHORIZATION FORM
Name of Property, Owner Applying for Permit:
-SA-c,K r 1l).
Mailing Address;
FA 130X �: nqq
Phone Number: f a Ca-Z1 03`13
Dee Freeman
Secretary
I certify that I have authorized (agent) LAN GC,2fL to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to install or
construct (activity) Ao s- k i
at (my property located at) Cof L Lj TAB PeA)"tJ,5.V1,4
This certification
e-h)
Date

'r-VV.C- C K4I 4mre
ADJACENT RIPARIAN PROPERTY OWNER S*TFWNT
(FOR AP&XJN.fiJA'1I',l GPWNG"0ATT1FT1BOA 0USE)
i hereby certify that I own property adjacent to J & c f < [ j s
(N. Rme of Propi Owner)
property located at EUi 1 U A
(Lot, BIoek, Road, eta.)
on ���' I , in C1�. �, i�t1AlSu1tC N.C.
T ('ute�rbody} (Tows► and/or C nty)
Applicant's phone #: �o -� i-"d � Mailing Address: =of Z � 7 �
He has described to me, as shown below, the development he is proposi at that location, and, I
hava rm objoction8 to his proposal. I understand that a pier/mooring pill / boatUft I boathouse
must be set back a minimum distance of fifteen feet (15' from my area 4 parian aepcss unless
waived by me, (If you �vish-to waive the setback, you must initial the ppropriate black
below.)
I do not Wish -to waive
' I d2 wish to waive that setback requirement.
--------..........W._.........__............ -------------------_ ._---
I)Eg 2,YPI'ION A"/OR DRAWlTiG OF PROPOUD
(To bg tilled in by individual pmposing devd,,
-- -...------ --- ... .— --------------- �_�. _....lie
(Information forProperty 0�%mer Applying (Riparian - riyr I4fornifiti0n) -
for Permit)
PA Bok BV
Mailing Address

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIE"®®RING PILINGSIBOATLIFTIBOATHOUSE)
I hereby certify that I own property adjacent to S�t-I� S 's
(Name of Property Owner)
property located at 1-ot 19 The V<wtj- vut+ cc? a,-T ,
"
V
(Lot, Block, Road, etc.)
on Cot► Mt(U a 1 l/� �-th%�4 , in ,12. L'0IJSW I CK.
N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: Ijoq-611-©3' 3 Mailing Address:1001 KOEC{ eA iL l)f, *-f 00
03
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,)
I do not wish to waive 70
I is wish to waive that setback requirement.
----•--------------------------------------------------------------------------------------------------------------
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) n
F,0,BOX .3S` 89
Mailing Address
1� rlotte,�� 2gZ33
1 S ri,�
s?2ture
-4P (A)S 16, c.l�
Print or Tvne Name

Division of Coastal Mgt. Habitat Impact Computer Sheet
licant: ��c�C L S
A-' -! Zi 1-i 2 F-.1)
scribe 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/or
temp impact
amount
f�
Dredge ❑ Fill ❑ Both ❑ Otherig
Dredge ❑ Fill ❑ Both ❑ Other A
3 l�
S�Y
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 ❑

RYAN D. COOPER
NCDL 8375610
PH.910-443-4829
P.O. BOX 1393
SHALLOTTE, NC 28459
PAY TO F_ lv
$ IHEORDER OF
State Em loyo eeffs''',,Credit Union®
V '�`tLSoP iCarolina
66-7704/2531 8844
DATE
81 8 � ►t, � ,
MEMO
1:2531770491:086143 20179ii' 844
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