56546D - Thompsom

0
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
everly Eaves Perdue James H. Gregson
'overnor Director
AGENT AUTHORIZATION FORM
ate: -N)0 0 3, 201 ti
ime of Property Owner Applying for Permit:
WibtoWi %c 7-i4omort)
ailing Address:
(0 52u e /4 %mil L 1 UT L
i LA410 G to U) k9 C 2M
lone Number: (I) 6 $ 6 ` 070 :r
Dee Free
SecrE
ertify that I have authorized (agent) ( f---9)3 % kI,1 to act on my
half, for the purpose of applying for and obtaining all CAMA Permits necessary to install or
instruct (activity) ri U JI--
(my property located at) .�-2O
its certification is valid thru (date) ( 2 o 1

i
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERB-IOORIYG PILLYGSBOATLIFT/BOATHOUSE)
I hereby certify that I own property adjacent to 15e1� � Ulak;
�t P ame of Property Owner)
property located at CoJOyo ���r� f r�
��� (Lot, Block Road, etc.)
on , in D #211oil&, ,N.(
(Waterbody) (Town and/or County)
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 se
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.)
do not wish to waive
t I do wish to waive that setback requirement.
---------------------------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCAI) in w
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Est. Wilmington,
DCM representatives can also be contacted at [phone].
No response is considered the same as -no objection if you have been notified by Certified Mail
(Information for Property Owner/Applicant
7Applying for permit) n
Mailing Address
City/State/Zip
(Riparian Property Owner Information)
i
Signatt
Print or Type Na.

ADJACENT RIPARIAN PROPERTY OWNER STATEi�NT
(FOR A PIER1iV00RIVG PILI_NGS/BOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to B i 11)lCK/ / /*I PSo�j
(dame of Property Owner)
property located at
(Lot, Block, Road, etc.)
on f Ct In �l��./.LJ �`�l��21� �� Ir" , N.l
(Waterbody) (Town and/or County)
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 se
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
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
/ (To be filled in by individual proposing development)
IA2 ew
If you have objections to what is being proposed, you must notify the Division of Coastal Management (DCNI) in w
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext. Wilmington,
DCM representatives can also be contacted at [phone].
No response is considered the same as -no objection if you have been notified by Certified Mail
(Information for Property Owner/Applicant
Applying for permit)
415A0
Mailing Address
Citv/State/Zip
(Riparian Property Owner Information)
S ignati
j
Print or Tvoe Na

Division of Coastal P09t, Habitat impact Computer Sheet
licant:
(�t'�li n �.�,,, Sep? Permit #: SZ.sVV/
cribe 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)
L
Dredge ❑ Fill ❑ Both ❑ Other
DDredge
❑ Fill ❑ Both ❑ Other
! Z
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
ZSZ
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 ❑

DELTA DOCK & BOAT LIFT 8209
PO BOX 3532
TOSAIL BEACH, NC 28445
l / 66-30/531
DATE !!! ` "'� 36 365
'O THE
)R ER OF
L L A R S B t o
First Citizens
Bank
firstcitizens.c�o�mJ r
FOR
0008 20 91I' l:0 5 3 L00 300i:00 3 5 3
199L5 41I■