54430D - Lazzo

ICAMA / DREDGE & FILL h
'EWERAL PERMIT Previous permit #
Aew ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
sized by the State of North Carolina, Department of Environment and Natural Resources
Zoastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
I R RUles attached.
it Name Project Location: County E/f -0' / C /C
V6F76 Ls7,-e T,41
> %7 l C017 -e State /'/C ZIP gy70
E (Y119) lS Y•3G7`'•Fax # (-)
zed Agent 6/! Pt,- ALd v,✓
❑ CW —TAW P"A L;" ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
Street Address/ State Road/ Lot #(s) S,09�� /--
Subdivision
City
ZIP
Phone # ( ) River Basin Z-",v
Adj. Wtr. Body , ;oy c e 70, C? ele .&
❑ PWS: C FC:
yes no PNA ye's / no Crit.Hab. yes / no Closest Maj. Wtr. Body
f Project/ Activity V /Ly R
a
(Scale*
)ck) length
)ier(s)
angth
amber
id/ Riprap length
g distance offshore
ax distance offshore
hannel
ibic yards
mp
use/ Boatlift
Bulldozing
i
ie Length
❑ See note on back regarding River Basin r

6C4 hkIt"LL—
CERTIFIED MAIL —RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner: Rod w x' Q 2Z o
Address of Property: 9 b% VooS e LQ p Q SW S C a l i A e- MC Q %�
(Lot or Street #, Street or Road, City & County)
Applicant's phone #: 9 1 o - `7 5 l — 3 0I D- Mailing Address: L4 b `% b & GQJ e— L-CQ >1 e c
ShatlaAA e- Sv c a%Y70
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this pel
has described to me as shown on the attached drawing the development they are proposing. A description of draw
with dimensions must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DC'
in writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive
Wilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No response i`
considered the same as no objection if von have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be set back a minimum distanc
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 wish to waive the 15' set back requirement.
I do not wish to waive the 15' set back requirement.
(Property Ow er In rmation)
Signature
C)
Print or Type Name
yto�(, boc)se L Q n e SW
Mailing Address
(Riparian Property Owner Information)
Signature _�_j_
Rck 1 n �► � W, e� t
Print or Type Name
g3 aS ed
•
Mailing Addres

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to R 0d M i ` Q Z2,0 's
(Name of Property Owner)
property located at H (A (e Goose �a n P_ '--Ad ,
(Lot, Block, Road, etc.)
on SCa Q CC (.; r�.e,k , in S ha 11()4 i Ck) , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #:g lU "`75 4 - 07,% Mailing Address: `4 io7(, G oase Lgr) e SW
shallo +Je n1 c -4SY70
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 (IT) from my area of riparian access unless
waived by me. (If you wish to waive the setback, you must initial the appropriate blank
below.)
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)
see- aifo.ed
(Information for Property Owner Applying
for Permit)
(Riparian Property Owner Information)
Mailing Address
Signature

p
Al
L rr o.
ZZ
0

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
3everly Eaves Perdue James H. Gregson Dee Free
11overnor
Director SecrE
AGENT AUTHORIZATION FORM
Date: 3 C)
lame of Property Owner Applying for Permit: Name of Authorized Agent for this project:
ec I'yl , a Z G re a Holden
Ili
)wner's Mailing Address:
y c,-n, Goose, Lane S\l
S kr1 H() 4k?_ N)c- aQ09_70
Agent's Mailing Address:
50a S+On c h n�_Rd
S LR N C., XI (o2L
'hone Number ' S 3 ©7 -1 Phone Number (I J O) Sy a - 9 T 3-I -
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):
1ec
(my property located) at H bl to
)se_ Lay\ e SW S
i/ This certification is valid thru (date) (% O !1
!` C"WI r /�
— A. V--

I
614

Division of Coastal Mgt. Habitat Impact Computer Sheet
)licant: kp
te: 312 ? %% li
scribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
Ind in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
bitat Name
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/o
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts
amount
Dredge ❑ Fill ❑ Both ❑ Other 0 1 Z Q7 1 12e
Fill ❑ Both ❑ Other
;omplete items 1, 2, and'3. Also complete
em 4 if Restricted Delivery Is desired.
Irint your name and address on the reverse
o that we can return the card to you.
attach this card to the back of the mailpiece,
it on the front if space permits.
rticle Addressed to:
Mr. -RoA ph H cweA+
93v Corpas Ind Sw
S1nC.1toi+r-NC_aW70
A Sigre
X
❑Agent
j
❑ Addressee
B. Received by (P '
C. Date of Delivery
D. Is del'
dress dell nt from ftbrn 1 ❑ Yes
If Y
ter delivery ,tress below.'' ❑ No
�y
❑ 1%ress Mail
❑ Insured
for Merchandise
4. Restricted Delivery? (Extra Fee) ❑ Yes
rticle Number
11: 0500 1111 3885
2004 Domestic Return Receipt 102595-02-M-1540
FECEIPT
�,ru
Ln
(DomesticMail Only, No Insurance Coverage Provided)
For delivery Information visit our webslte at www.usps.com® I
Ln
_.
_. Postage $

HEIAti
910-842_9732 HIS NCDL 4576438
1502 STONE CHIMNEY RD SW
SUPPLY, NC 28462
`ll �1ACCAMAW
Supfl NC tire?
: www.wnr:ra*mwL nk.r.om
t:053112IS 21:8000 IS? 53011'0359
HadaeO Clarke
$ zoo, o�
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