56503D - Fifth

CAMA / DREDGE & FILL
3"ENERAL PERMIT Previous permit#
IV,ew Modification ' lComplete Reissue Partial Reissue Date previous permit issued
>rized 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 / 11•
[Rules attached.
it Name, /�h -4.;, Z C Project Location: County
%!P 1 Street Address/ State Road/ Lot #(s) 192 6.4,s �
rl 'X /a'" d1i , .4 - State �%j •� ZIP
k(<titi��b> Fax#()
ted Agent To 4, , l✓�s %
❑ CW aEW ❑ PTA C, ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA F1 N/A
❑ PWS: ❑ FC:
Subdivision
CityC)CoA.,) '�!d e &1-9c Ai ZIP 2 F
Phone # ( ) / River Basin Z",
Adj. Wtr. BodyOZia -ouN-Pl e Za l
yes PNA yes / Crit.Hab. yes / no
Closest Maj. Wtr. Body A' ''J w
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f Project/ Activity P P2 d t-Z c t
� (Scale:
.ck) length F ,3O x k
n(s) u
�ngth
mber
d/ Riprap length
g distance offshore
3x distance offshore
hannel
bic yards
np
ise/ Boatlift
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I See note on back regarding River Basin ri

/6

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
3everly Eaves Perdue James H. Gregson
governor Director
AGENT AUTHORIZATION FORM
Dee Freema
Secretai
Date: It - Z —/ a
ame of Property Owner Applying for Permit: Name of Authorized Agent
//for th7.-
roject:
F�� i S7-aeeT ,S,g.,, �rrarr�tGk _ oc.f�JLZ�G�
4LC-
1wner's Mailing Address:
170 LA- 5 /
��e,r s�.,p�et r�- t✓ �
ZZ3af3
'hone Number (70_� _ Z 2 G 3 4
Agent's Mailing Address:
I C 9 baiC �G't-Cak- G r 2
D C_&*W to `ic 13 /►2 0
Phone Number (/a) 3C. ? — C 9S Z
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
)r and obtaining all CAMA Permits necessary to install or construct the following (activity):
Zrno` F?iCS 094,09'i P -
my property located) at 190 1g) q Z S
-his certification is valid thru (date) 5---2
/nr V_ //-Z—/o
Property Owner Signature Date

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1I, ora�►7(r»�►�-59-91 -,Ssmppy e5li ?sb7"23 -v/S =V "Mids.IweMdd3/
(I'N103 .iorpar a a:31)
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HAND DELIVER
Ilo
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(TOR A PIER/MOORING PILINGS/BOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to Pk , 1 14 o(G om e— 's
(Name of Property Owner)
property located at 19 0 w TZ, , R- b •S 'T'
(Lot, Block, Road, etc.)
on in o'c�e4qr3 Is. fie Aeg c� , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: 5i'/o - 3 6 7 - c S s Z Mailing Address: e t<<lc-
�r ti
Oce--,4a-)I5%r t3eAcA vG
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 / boallift / boathouse
must be set back a minimum distance of fifteen feet (I T) 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
I do wish to waive that setback requirement.
-------------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing; development)
w, et,sperj�
(Information for Property Owner Applying
for Permit)
wrc"mC
-----------------------------------------------------------
(Riparian Property, Owner Information)
Mailing Address
ocO440i W. l e k-� em&4 A-#-
Signature

: Division of Coastal Mgt. Habitat Impact Computer Sheet
/� C/� stl w 15-lee err
)ficant: /C i 'l l� s102 & i/ 5, Permit #:
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 fina
disturbance.
Excludes any
restoration and/(
temp impact
amount)
Q (,�
Dredge ❑ Fill ❑ Both ❑ Other
3$
J$/
—, /
Dredge ❑ Fill ❑ Both ❑ Other p
1 J20
43 ZD
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 ❑

JOHN R. WEST 21761
DBA WEST DOCKS
1595 CROWN CREEK CIRCLE SW FIRST BANK
OCEAN ISLE BEACH, NC 28469 OCEAN ISLE BEACH, NORTH CAROLINA 28469
(910) 575c5271 66-456-531
)_J
AUTHORIZED SIGNATURE
112 n n n 7 1 r7 r„ ---
-" " ' C3 •H- '•U O4 5681: 79 100 13198118
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