54502D - Reynolds

!CAMA / ❑ DREDGE & FILL s ;?
'ENERAL PERMIT Previous permit#
New ❑Modification LlComplete Reissue El Partial Reissue Date previous permit issued
•ized by the State of North Carolina, Department of Environment and Natural Resources
;oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC 4/`� /22 �G
-,-� � [slRules attached.
t Name ,/?Iz wq'ir /� /1 C ' s✓�? e�� Project Location: County , /�/� 1 /N S t✓/ t /
j � & t L j t-" j!�"f}1 i Street Address/ State Road/ Lot #(s) 12
im _rs is y,✓ _ Stated ZIP , 2
(JJjk) 24-7&)J Fax # ( )
ed Agent ,i . C. el q .Kf
C CW ❑ EW ❑ fqA O ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑ FC:
Subdivision
City e9,::y4 ZIPS
Phone # ( ) River Basin
Adj. Wtr. Body rl�7,10 r% /r/ W (na16
yes J,-,'ho. PNA yes no Crit.Hab. yes / no Closest Mai. Wtr. Body
' Project/ Activity . � r�4 l f %y f>L, !/rt i 2
(Scale:
rk) length Ik a(y «BSI �q
ier(s)
ngth
nber
i/ Riprap length
distance offshore
x distance offshore
cannel
sic yards
rip
se/ Boatlift
ulldozing
❑ See note on back regarding River Basin r

d
f �G�
� ple
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8

Ai
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverty Eaves Perdue, Govemor James H. Gregson, Director Dee freeman, Secretary
Date S— f q_ /D
Name of Property Owner Applying for Permit:
Mailing Address:
I certify that I have authorized (agent) 6114�J to act on my
behalf, for the purpose of applying for and obtaining all CANIA Permits necessary to
install or construct (activity)
at (iuy pi open y located at)
This certification is valid thru (date) cJ a,-7eo
/k C=1 C-� /0 4 - "T

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to
ame of Property Own )
property located at L J� 1-
(Lot, Block, Road, etc.)
on , in C) o by, -LL 13-0 Y 0° , N.C.
(Waterbody) (Town and/or County)
Applicant's phone #:336 "7O to - Mailing Address: 4319
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.))
A/ 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)
4- 44. O Sp
-------------------------------------------------------------------------------------------------------------------
(Information for Property Owner Applying (Riparian Property Owner Information)
for Permit)
Mailing Address ture

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSIBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent tQ 's
(Name of Property ner)
property located at '14141L Tt _�� ,
(Lot, Block, Road, etc.) /
on , in 60 Gall ;-LEL �8-0( _h_- N.C.
(Waterbody) (Town and/or County)
Applicant's phone #: 336 '7-*6' 7/,0 3 Mailing Address:- �'�(yi 1C A
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.)
11-�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)
Sig
(Information for Property Owner Applying
for Permit)
Mailing Address
(Riparian Property Own Information)
< to �-- -14:
l Signature

Division of Coastal Mgt, Habitat Impact Computer Sheet
licant: 602X -✓ el'4 a C cols Permit #: t/ S 6-2
cribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
id in your Habitat code sheet.
4tat 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/o
temp impact
amount)
V (�✓
Dredge ❑ Fill ❑ Both ❑ Other
2 oo
Z G�
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 ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

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Post office U.S. Dollars and Cents
:Year, Month, Day ffv]M���W
Serial Numberr .r.
2x
17 5 0 9 6 8 8 5 4 8 L Amount TUB NUHDRED DDIIARS Una Clerk
Pay to From
Address Address��
r1 !Yf/h �i
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Memo it /r J/1 —
—SEE REVERSE WARNINGOTiABLE ONLY IN THE U.S. AND POSSESSIONS
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