56562D PLeasant

ANA
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
3el F. Easley, Governor Charles S. Jones, Director
Authorized Agent Consent Agreement
William G. Ross Jr., Sei
f<1n�m 1 is hereby authorized to act on my beh2
(Printed Name of Agent)
�r to obtain any CAMA permit(s) required for the property listed below. The authorization is limited to
is activities described in the attached sketch.
,TION OF PROJECT:
I6=
ERTY OWNER MAILING ADDRESS:
PHONE NO. 9 lg - 77— !o$S�a
DRIZED AGENT MAILING ADDRESS:
fS�iL©
PHONE NO. g /O ~ 3.17 3 N 1,6-'
--- - L - . V / (IU/

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to -:7�N,: A AJ�, is
(Name of Property Owner)
property located at 'fib 9? ?r N : S'T ,
(Lot, Block, Road, etc.)
on CAuAL , in -5.�AF C' T!! , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: c119-l7,-� —GS&I Mailing Address: 5ta &
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.)
�X I do not wish to waive
�X I do 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
for Permit)
aaa� rnr�S Pa, � 1.,r.1
Mailing Address
(Riparian Property Owner Information)
Signature

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C Division of Coastal Pr'9glt, Habitat Impact Computer Sleet
plicant: �9 /+�/ - Permit #: qPJ(��
tee
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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/oi
restoration or
and/or temp
restoration or
temp impact
temp impacts)
impact amount)
temp impacts
amount)
\
Dredge ❑ Fil11A Both ❑ Other ❑
5
�5
Dredge ❑ Fill Both ❑ Other ❑
55
5S
Dredge ❑ Fill ❑ Both ❑ Other
U5
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredciee 0 FillE Both R Other 171
■ Complete items 1, 2, and 3. Also complete A.
item 4 if Restricted Delivery is desired. X
■ Print your name and address on the reverse
so that we can return the card to you. B.
■ Attach this card to the back of the mailptece,
or on the front if space permits. 4sy
D.
1. Article Addressed to:
fYlAQ1C �� i2�Ck..�A,r.1D
i
i tiJ� urn »•1C�`it�i�! , IS C �yoJ
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❑ Agent
Addressee
C. Delte of Delivery
Is deTv4q aHtlrae§'differerrt from Rem 1? U' Ye:
If YES, enter delivery address below: ❑ No
3. Service Type
,;lMerttfled Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? Pft Fee) ❑ Yes
7009 0960 0000 6030 9689
Domestic Return Receipt
1 o2ss5-02-W1540

ANTINORI CONSTRUCTION
145 VIRGINIA LANE
SNEADS FERRY, NC 28460
[phone]
5�-5Cc,� D C Orz-.
BankofArnerica. 8873 ��
ACH R/T 053000196
66.19-530
1180088 7 311' 1:0 5 3000 L 961: 0006 50 5 2 19901I'
_.aG &z i :16 in
DOLLARS
8
AUTHORIZED GNATUR