77242_Patrick H. Brown_20200818

i -______ V,0 ,
=fl 3 MC:
:A CAMA/ ❑DREDGE & FILL N° 77242 A - CI
GENERAL PERMIT Previous permit#
ONew ❑Modification OComplete Reissue OPartial Reissue Date previous permit issued 1-4 '1
As authorized by the State of North Carolina,Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC d'Z'N • t-z-o v
®Rules attached.
Applicant Name1Arr-gz+G 4. ' pw 4 Project Location: County 3-c-qa.%Fay- i!o,
Address moo. 3crc -le, , I59_ '$A-ivIv.W'I`est , Street Address/State Road/Lot#(s) oc- S't_. l'n'
City iA tii State 14-e- ZIP 2-)4s f LD 1 c9-1 '3 v+E"- "19 .
Phone#(qil) . 24 - 4)/SSE-Mail -_ Subdivision 1�- y v izu)
Authorized Agent-1-7 I i 5 14/1/ i City 4-1-1- ZIP -2-7 o
Affected ❑CW tioW JPTA ❑ES ❑PTS Phone# ( )_ River Basin-rAiz.-(+'+t-t 1 C c
s 00EA 0 HHF /❑IH 0 UBA ❑N/A
AEC : ❑PWS: Adj.Wtr.Bodye-RnAL.,t to�-12i u - Ciama /unkn)
Closest Maj.Wtr. Body
ORW: yes no PNA yes ILL,w'12`u L ,
Type of Project/Activity its k b' '1?i t'v, , 1(o' y I (n' -;':".4^4e13e 1 I`Z 'x f-D- -Pc -.rilM
► ' x ''3o[4-yet (Scale: 1~, ...
r
r r
Pier(dock)length±trjD'� fo' � - _ _ '
Fixed Platform(s) /A-''e 1`' i ' r T.._ + (. ; i... 1
Floating Platform(s) _ ' _ i t I '
Finger pier(s)j2 -x 12 i i.. ' : rt. _.
� , --I- -- � "tom --� �-1- '_ i -r -i--+ - � __ ___-i.
Groin length r + i I i-- —I--�^ I i 1
number }_.. I i _ ..I. I j { i j }
Bulkhead/Riprap length I _L_ 1.. _ `' E .) _ i i il_ ;. :-.. kr, _ 1. ,Nt ti'C t 1 110'' c Co.r. i -
avg distance offshore i j_ I j ! / j j I
G
max distance offshore I i _ _� . 1 i f 1 i
� i It
Basin,channel ` _ _. f. . _ 71 ' , .1___. I. __i. . __ t f
cubic yards - .. v `_ j :_,_�.j. i. } i I. a_
Boat ramp i i s�►,II�J✓�srt�p _i ( I_ i )'1 'r r i
i J*""'`—;- - ;f ;-- 1
Boathou Boa i -j- - - _- I._ •r1r1 �._� ��yt.!� - --
i4 _ i
t
Beach Bulldozing -I . s.--.'. -{.__-_i . i i__ _._!_. 1 1---1 i 1 _ '. _
Other - I I--"
i : 1—. 1 t• !1, .
Shoreline Length ; _ .
SAY: not sure yes Z ' i
Moratorium: n/a yes �' q : - ..._
- I
Photos: yes no (r t � � ;-_.a P¢�f . ' _ , � i __ � f � �-�� - -,_�
Waiver Attached: yes no �'�- j4 P�1M^2.140 A I ;_I i i __-_--- 1 y_
A building permit may be required by: Eps.,aT Co, See note on back regarding River BL'in ,
(Note Local Planning Jurisdiction)
Notes/Special Conditions / '-- ie „�,a,,-lo p,,'...}-G-,p L,of,.'',L.
1
ill 1 f
A k fr-60 __A-.(7 _____ 121,a.--7 .
•(_, .rimed Na a Permit ficer's Printed Name
4
� ! •
ignature r Please read compliance statement on back of permit** Sig-"a=" --''' -------T(__----"')
}_1' m
a(- _ ' 7--17 62-r-- IJ7L i J-2;_ -2 f7 /' -• /er - 2-o 2c]
Apcation Fee(s) Check# Issuing Date Expiratgn Date
I

1
A. •11 CAMA/ ❑DREDGE & FILL PTO
GENERAL PERMIT ly Prevo pe�it# A ©t\)J D
❑New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina,Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC 4."1/4 - t'z-o C.'''
®Rules attached.
Applicant Name' -rgaLf-. 4- --&zzo t1 Project Location: County 3�A,A.-1 Fc --i Co-
Address(P0- e o c -10 , 1591 'A7vis w"P---.6) , Street Address/State Road/Lot#(s) p i - ct. t'Z+b
City ci- A'1'--1 State t -G.- ZIP 2--)4f e 1 S`3-1 3A yV,e 11zd1 .
Phone#(q11)624 - al t SCE-Mail Subdivision' y 1/tZt.4-
Authorized Agent—r7 J t S vVIAe• 1 L City r5/vt-1-3 ZIP i i' o eK
Affected ❑CW YW ;PTA ❑ES ❑PTS Phone # ( ) River BasirrjA2-(7 -tN -i (v
AEC(s): ❑OEA ElHHF /❑IH ElUBA ❑WA Adj.Wtr. Body'Mt.-t ' t v c& (nat�/man /unkn)
❑ PWS:
Closest Maj.Wtr. Body 9ARLAev `U -x_
ORW: yes no PNA yes 123
12,z Y to E , ,
Type of Project/Activity i t5i5 b' ii7t vvt , 1 CP' y I co' , 12 'x ( -- P( = o t
► 3�%r 1212,(1ti.'t--r (Scale: I = j ' )
Pier(dock)length{1d5b'?; b'
I , l 1 1
Fixed Platform(s) t f- x 1` ' I
4- ?4'"L,2v v..'z4Y
Floating Platform(s) '22 ff � b LP,- F l ,x t_d t I
Finger pier(s) y'2 t•x i•Z ' t
Groin length - - , 1 N
number -... . . — I
rt ' ! < l/tZ E 1(d ti
Bulkhead/Riprap length — 1 p,cam¢ t�_t, S• .'
>_ 1
avg distance offshore '
max distance offshore I j
l
Basin,channel
} E
cubic yards i , i3' —L-'8V�t- I
Boatramp te.Jto✓&'new -._ l2'+' i2 ' ,
13-) r,,,r1t- t ) ten.-1,,:cn ) 1'r-on ;
Boathous 1
1-3 'X �3 -4 --r-
_I— i ___1
Beach Bulldozing —'
Other
Shoreline Length -1 0 in I C
SAV: not sure yes no i it utiC= `- ,.. 1
�2ow e� — t E• 1
•
Moratorium: n/a yes cod-) ^ 't- v 13t io w rJ i..... ? 17.�?3er ez,iN)
L. 4¢,.,.p I �'2 o d'
Photos: yes no 1
Waiver Attached: yes no �'c. 17--c) ' Pc�.P _ 1
A building permit may be required by: ,4-1.am Co. See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions 4e.,"r iS ,✓1a,,.ij-Q•,A.4-c,0 L00'1-'r1/41.•
Agent or Applicant Printed Name Permit
Iccer's Printed Name*Please read compliance statement on back of permit** at�co►
Signature p p Sig
0.
U1/L 1 -t9 137// g -J-2•Zo'Zt7 /2• /z- - 2e)2-0
Application Fee(s) Check# Issuing Date Expiration Date

r
Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar-Pamlico River Basin Buffer Rules Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-6481) or the
Wilmington Regional Office(910-796-7215)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-648 I
Fax: [phone] Fax: [phone]
(Serves: Carteret,Craven,Onslow- (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden,Chowan, Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

011-K CAMA/ ❑DREDGE & FILL N° 77242 A B' C D
GENERAL PERMIT Previous permit# r i ;
>' ❑New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued t , 1
As authorized by the State of North Carolina,Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to I 5A NCAC '
❑Rules attached.
Applicant Name ,.- i') ,i ZJ c,) Project Location: County
Address 13`+ I ',\'/I,''L Street Address/State Road/Lot#(s) `) 1- >Z I") A--b
City 1 r' State I - ZIP > -<•• '-4 ) \-- _, ,/v,C " ;
Phone# (_) 7 /- - E-Mail Subdivision _1� ,_ -n ,.J
Authorized Agent-'T :.T '. 1, .,K City !- -t-i-1 ZIP . , n-4
❑CW l'EW PTA ES ❑PTS Phone# ( ) River Basin C. ✓,'„ 1 I ,,)
AEC(s):Affecte IIIO� HHF O El
❑UBA ❑N/A Adj.Wtr. Body i - , , (nat)/man /unkn)
❑ PWS:
ORW: yes / no ) PNA yes
Closest Maj.Wtr. Body 1 '" '
Type of Project/Activity l ' v, >:_,( . 1 �., ,_>," \ -Y
<-_-r (Scale: i ' : ' )
Pier(dock)length I--') r
Fixed Platform(s) I A., 'v '4.0 '
Floating Platform(s) 44' f
Finger pier(s) ■
Groin length � 1 1
number ---. _ _._..........
Bulkhead/Riprap length - �-' ■ { ^ �� c., �" el
.avg distance offshore III1 —�■ I=
max distance offshore
Basin,channel ' • ■•—_SR_S_MI
cubic yards �� ■ ■ ■■
Boat ramp i.4...111..,r)/ ,-•J •
Boathouse/Boatlift'
ll
Beach Bulldozing - ■ III -- 11111 as
Other
all
•��MN II Ili 5 MIll
Shoreline Length - ' [�0 1 1 1 111-111111
SAV: not sure yes no
Moratorium: n/a yes _._...' ,i I ; I �...' P r.....�Ir�
Photos: yes no ; i __ 4 i cis, .,.'. ! _`12; , ....
Waiver Attached: yes no It%)'' '- , ' 'k:, '
A building permit may be required by: 1j,,ia t-,.=- 3i�� ,-:...,. . 1ZI See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions - 9 c,;..:-c-i ) .,..t' x•-...
Agent or Applicant Printed Name PermitOffficcer's Printed Name
Si nature **Please read compliance statement on back of permit** Siture1
g P P TM
lj7i/ ? •i • ;,--�„-( , 1 _- • « • _ --) =c—.)
Application Fee(s) Check# Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar-Pamlico River Basin Buffer Rules Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-648 I) or the
Wilmington Regional Office(910-796-7215)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves:Carteret,Craven,Onslow- (Serves: Beaufort, Bertie,Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
40 I S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden,Chowan,Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

OE CAMA/ ❑DREDGE & FILL N° 77242 A BCD
GENERAL PERMIT Previous permit#
)G ❑New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina,Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC .
❑Rules attached.
Applicant Name Project Location: County
Address Street Address/State Road/Lot#(s)
City State ZIP
Phone# ( ) E-Mail Subdivision
Authorized Agent City ZIP
Affected ElCW ❑EW IDPTA ❑ES ElPTS Phone# ( ) River Basin
AEC(s): ❑0� ❑HHF ❑IH ❑UBA ❑N/A Adj.Wtr. Body (nat /man /unkn)
❑ PWS:
ORW: yes / no PNA yes / no Closest Maj.Wtr. Body
Type of Project/Activity
(Scale: i )
Pier(dock)length
Fixed Platform(s) I IIIIII■■■■■■■ II■■■E■II ■■ i
Floating Platform(s) j 1 tn 1 ■■■■■■■■ . .G;� . -11' ■■■_----i— ;— II
—
Finger piers) ...._. . .a......i.._.._...
, , , ,
Groin length :
number — -..1. r. _ i
Bulkhead/Riprap length — — .,
— i_
avg distance offshore ■■ ■■�.■ ■■■■. ' ■■ 1111111111111
max distance offshore j i
Basin,channel
imilm
gilililui
II
cubic yards ■■ •■■��■uu■� ` _.. .a■ ■■■
Boat ramp !UIII
r�. + L':'
_. •' fit.. _.._..... .._.....
■ ■ C 1 i I ■
Beach Bulldozing — IIHhIIIH
11111111
I HHhllI1I
Other 11
11.1111
11111111j
III IIIII
Shoreline Length H1111111U11111H1 I : :
i
SAV: not sure yes no -
Moratorium: n/a yes no- i i•
Photos: yes no -�.. ;
Waiver Attached: yes no - I i A 1
A building permit may be required by: I See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions -
Agent or Applicant Printed Name Permit Officer's Printed Name
Signature **Please read compliance statement on back of permit** Signature
Application Fee(s) Check# Issuing Date Expiration Date

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that I)prior to undertaking any activities authorized by this permit,the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowner(s).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief,certify that this project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
Tar-Pamlico River Basin Buffer Rules Other:
Neuse River Basin Buffer Rules
If indicated on front of permit,your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Resources. Contact the Division of Water Resources at the Washington Regional Office (252-946-648 I) or the
Wilmington Regional Office(910-796-7215)for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Morehead City Headquarters Washington District
400 Commerce Ave 943 Washington Square Mall
Morehead City, NC 28557 Washington, NC 27889
252-808-2808/ I-888-4RCOAST 252-946-6481
Fax: [phone] Fax: [phone]
(Serves:Carteret,Craven,Onslow- (Serves: Beaufort, Bertie, Hertford, Hyde,
North of New River Inlet-and Pamlico Tyrrell and Washington Counties)
Counties)
Elizabeth City District Wilmington District
401 S. Griffin St. 127 Cardinal Drive Ext.
Ste. 300 Wilmington, NC 28405-3845
Elizabeth City, NC 27909 910-796-7215
252-264-3901 Fax: [phone]
Fax: [phone] (Serves: Brunswick, New Hanover,
(Serves:Camden, Chowan,Currituck, Onslow-South of New River Inlet-
Dare,Gates, Pasquotank and Perquimans and Pender Counties)
Counties)
http://portal.ncdenr.org/web/cm/dcm-home
Revised 7/06/17

Authorized Agent C'onsentAgreement
a-tD
• OuJA/
(Property Owner(s)) herby authorize Tobin Jay Tetterton of
TJ's Marine Construction,LLC to act on my behalf in obtaining CAMA permits for
the location listed below.
PROPERTY ADDRESS:
c&\ U‘'eu
PROPERTY OWNER'S MAILING ADDRESS:
Phone No.
PROPERTY OWNER'S SIGNATURE:
AUTHORIZED AGENT SIGNATURE:
T BIN TETTERTON
DATE: (l 2(e°
W/Authorized Agent Consent Agree.

4P .3f$csIrl- PROF CTNIME STATEMENT
� q /#hereby om;L r3 I own property adjacent /Lr KJf
s
property located of id
(/.'Bo�P®restj Snrev;.
_Arlon _1.��_ (Adc1r, �o
f°�ifaEoPbe�d'f) 'in (i�r..� t,e7 /' ' -N.c.
l /Town and/or County)
. The applicant has described to me,as shown below,the development proposed at the above
io on,./
.41tvast _V :have no objection to this proposal
r r.�ti.^l;•
� � i have objec+tons to this proposal.
DlE^-a.Rip u7b3i19 AND/OR 9 ieiFptiEP�SSe®®�DLOP AEArf
(Ifd due;proposing, development must fill In ci scripf5on below or attach a-,te drawing)
06Q 1-
/e4 i
t of ecr Aoc.
WAIVER SECTION
•��:r_ i understand that a pier, dock,mooring pilings,boat ramp,breakwater, boathouse,lift,or groan
.,:!=r must be set back a minirr:urn distance of 15'from my area of riparian access unless waived r y
, . me.(if vo wish to waive the setback,you i29s ithe appropriate blank beiow.)
i do wish to waive the 15'setback requiremero't.
__!do nos wish to waive the 15'setback requirement.
Trop`S yf" ,�a
Owner'information) (Adis , Property a
9 Iuufo>rwftn) i
f
Signctiz e
Pdnf or type Name �� /�S011 ronn�jlt�'��F./S L�
%!. 9. 0 euJ Print lo'e(/�Qe q
a �, z bow ti g;eA+-p ssNCi
City c
�J �— o` :'r�5 C ate/4
telephone Number/email address Telephone Number/email address
Date
Dom=
'Valid forone caiead2ryear (Rsvieed Auc 2�i4z,%
after siona re=

NER
hereby certify that? own property � ` EME "d
p perty adjacent to .' . /4 i PD
property located at ------_ _ R6 f�
I,� 7 �? ` .. o�(Nam of Property o ner1 s
on - _.0 c. .l�1 jh (Address, �a Block, 0 3
---- a�, etc,
taterv� r-h �cF� 1' (� r
The applicant has described to ( it/frown and/or County)
N.C.
location.
me, as shown below, the
development proposed at the drove
-- _ 1 have no objection to this proposal.
1 have objections to t.
'pis proposal.
D"SCRIPT ON AND/OR DRAW ; F
des a�w
ophzen Gust rill l n i11 x i t� ri 9 ._....
craotio r below or
j ���/ / ac ? site_fir-,y°:',ns.
understand that a i `Al E SEC 1
.-. pier, dock, r}i
must moon
or groin
the f ,, n i se. ,. , � 9 pilings,s
a- boat oa
ril n breakwater, boathouse,
e wi i x ry
s m h �
waive the setback you mUet i'm, area of r+p ri an access unlessr wSaived by
....-...�..�, '�E� appropriate, blank below.;
---_ dowish to waive the 1 �.
E'.
o'setback requirome;t.
c''y°11
n `nllSii 0�N ,
_ _ ai!Q t_i�e ?y sathoc, ,:?(rel.
(Property Owner
rfo .t°a*
i_Aoliacent Propel-4 'Owner inrormation)
Sig,natu e
l r u vl S'iglatur�e*
Print or Type Name _"`-- -m I i
v Prirt or Typ 1 _�.
City/Sta e2 2��u i� ' llin.�.4._cIra
l.
� r;
7 City/State-ip
Telephone Number/email address
- -- e i 7- ZJ Tefepho _as 31v �nr��, l�a; rYYi�(. car?1
Date ne,l�,-,Lar.�em:�;i 3rrcrress
D_Le.
for`n ;.�.i;enJ r year att '{>.�..t
8ii�riGlfC!( -
y.l-. ',i,Ai Aug. 2014)
.

€ DJACEN a RIPARIAN PRO Ob i qig a
i hereby3h;, cer tinproperty adjacent
that I own grope to g ,
property located �^ �--
at 1 �� ,, ( ei,of Property:Owner)
c" `s' (Address, Lot, Bloc
a.�= , etc'
:;Alaterboci(r,� ""`--.--, ire�. ' 3g . A > :
(C t',yToviin andlrrr Count! ) N.The applicant tas described to me as shown below, the deg!
location
development proposed at the abode
: ------- I have no objection to this proposal
! have objections to this
ENT
f' DESCRIPTR�9E�i s�4®/ �9P�a qa r ,. g� p� pq
r - _ .0 B tar...,./sy,y <.":'.Z fill 0. POP<..n'So-ED D.S../tea
muse fill in ies;_i� Lion _. ,. flPhf
�-� B aeie�or attach a sit�o° �.� ^g,�
}
I understand that a pier, dock, mooringWAIVER SECTION
must be set a minimum distance of 15' from myarea pilings, boat ramp, breakwater, boathouse, (i�, or groin
mu ti€e s wish back waivem the setbackistanyou must
a op€riparian access unless waived by
Mal the appropriate blank below)
-- do wish to waive the 15'setback requirement.
------- ' do not wish to waive the t 5'setback.....�.� rw^uiroment,
Owner(rsf€�ruax6a�n;
/ .x d ac2nt 'ropey Owner Info rmation)
S= c�tur1.1? ,
Print or T e '�`: �t� e
iVame.
it
ame Print or Tripe Name
/�7
pi Sa :u,,-�Aanmd� ss fling !(rPrYs, _?
0City/$tatea Gify/StrtF/7in
*elepone Nub email address
Da— te
'/7 Z hone 3„address
Revised Aug. 2l+ )*✓alid for ore sale uer year after signature'

NC Division of Coastal Mgt Habitat Impact Corrtp-uter Sheet
Applicant: FATRT C k 3 RDW LJ •
Date: - I -202425
General Permit*: 1 Z Li Z
Describe below the HABITAT disturbances for the application. All values should match be name,and units of measurement
found in your Habitat code sheet
TOTAL Sq. Ft. I FINAL Sq. Ft. j TOTAL Feet I FINAL Feet
(Applied for. i (AnticipatedFrtal I (Applied for. ' Anticipated final
DISTURB TYPE ! Disturbance total , disturbance. Disturbance i disturbance.
Habitat dame Choose One ncludes any Excludes pry total includes I Excludes any
anticipated restoration any anticipated restoration and/or
restoration or and/or Temp restoration or temp impact
temp impacts) impact am cunt) temp impacts) amount)
•
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D W I Dredge❑ Fiii❑ Both ❑ Other j j / y9 Z /09 'I-7
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Dredge.: Fill❑ Both ❑ Other ❑
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Dredge❑ Fill❑ Both ❑ Other ❑
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Dredge❑ Fill❑ Both ❑ Other ❑
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Dredge❑ Filt❑ Both ❑ Other ❑ j
Dredge❑ Fill❑ Both ❑ Other ❑
I I
Dredge j Fill❑ Both ❑ Other ❑
j I i
,1I
Dredge❑ Fat❑ Both ❑ Other ❑ '•
! i I
Dredge❑ Fill i❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both ❑ Other ❑
i ; I
Dredge❑ Fill❑ Both ❑ Other ❑
I ! ! I
Dredge❑ Hl.❑ Both ❑ Other ❑
I I
Dredge❑ Fill❑ Both ❑ Other ❑
Dredge❑ Fill❑ Both ❑ Other