77269_Chris Garltress_20200908

_.- ____._.___.._-_.__. ti...__.. K�
a AMA/ DREDGE & FILL --nD vt,0 610 9LI 1
1° 77269 A C D
ENERAL PERMIT Previous permit# )"
)�• & ew DModification DComplete Reissue DPartial Reissue Date previous permit issued y iA
As authorized by the Stare of North Carolina,Department of Environmental Quality
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC 01 f4 • l-2"4.)v
I,y.,Rules attached.
Applicant Name G'F•1¢1 5 6,A T4-6. -5 -, Project Location: County 'a r T3c 1- (e) , _ -
Addreess ) l'-) .0 r"3,r-) T'•c.sk . Street Address/State Road/Lot#(s)
CV6'2c t-•t. v i,-i.€ State Ti' .-ZIP 2^)S>54S 3117.2• f.,,z ,�^r w v 4,14, 'T�
Phone#( _) E-Mail Subdivision Ge,•7•s/ Q �2 �-3
Authorized Agent { A. PAR. ,)-c L
S ._L.i t tn- City�c.lr'-' ^Z:t _ ZIP 'Z'1 cS' ?I..
Affected O CW F p$rA ❑FS OPTS Phone# ( )--._.__. River BasirrT-6(_._�A.�-,.�(0
AEC(s): O OEA 3 HHF CI1H ❑USA O N/A
O PWS: Adj.Wtr.Body�A M1,.sZO -0 t Vr'YL maniunkn)
�'e ^'Z
ORW: yes ! —Th PNA yes no Closest Maj.Wtr Body-- �� Q ! P�J_•
'l
Type of Project/Activity "' 13 �. +3 r-1 c v v en m 30k-y-s,i,'.
(Scale: "t 3 1 1 )
Pier(dock)length __
Fixed Platforms)—_, 1--1----.--___.-_1H !._..-___-_- -;....�.. .i_._!.._ ' C'''! !- 7,.. 1 I
FloatingPlatfotm,(s) - -;.-'r- --- ---1:-.
�. j_ . .. • ; !2M
_
Finger pler(s) _
Groin length ' { --1-- ' ,--^--- i 1'� rt 13 —'-_ I__.-_ -' /_ h 1 I -
I aT� rr . • ' �Ilp--__ 'I . �t?c rJ..j ,
number i 1__L _,_ ! .-_•I&�h't-trt*DJ: q I -L r Ql).t.r�
Bulkhead/Rlprap length y._•�—•1.--•r-•---i—1--_j_-._ ! i I t _ -!-_4 __ i .. :sc.', t;t.c f
a distance offshore ,:� —(__.I _;____.__ ,--1't -; I_ r`` __.._ ; i' i
T :
max distance offshore 1 1 _.r_' _
II
a
Bann.channel J.._�'_j—_I _�i.. _ _ ' _ , --I - --
I
'�
cubic yards ti {. [. I. } i r r- - - - � Z -I ...
i r i.-
Boat ramp �� � I !-i- i i ....._:-_ . ;;-7•.,�
pU�p Oa i �Lt J G d?y� ' i 1 ! 1 1 _ ` _. i..— _ _ __
Beath e D
:
i _
,
-� _ _ j l =r
Beach Bulldozing 1 i ' ' i ' ! ... - -. . . , i^ - ,` ... _.'._.
,_
i
----- —I—
• }
Other l ( 1 __� l.i� ; —i
I '
t
Shoreline Length I � ` r 1 I l 1--1 1 i 1 •.--.-.._
1 l 1 t - l —
SAV not sure yes no �_t -r— --- �� •--• • ; _1._. _ - _
Moratorium: If
n/a yes x'.• Jir7 F i } ! _
:
Photos: yes I '4 f4 Pr i 4-.- .,f.. _._I.._. 1
WaiverAttachod Cy © 1 ! I L ! i l i _.-!._.. 'e 1/2.•-___-_,
A building permit may be required by: V T—o-n-s— 4"° • • ee note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions ^'j-'S '?eel.vt 1't" L-\Nl,-t-5 " ' ,L'Ytr --- 2 i'x Cy)
'�c.)().-•,- 51_. p', -
11
•
C1 l r .- 7aY 1--�J 9,v yr- _.._._...-
Ag Applicant Pri d Name PermitOf ers Printed
�� •
_ �--�
Signature "Please reac compliancestatement on back of oe-Ppermit°" 51 tuP
-U)i - z-o v-- 2 �, J 5 �� '�" ,>/ }a ,/ `(
Application Fee(s) Check# Issuing Date Expiration Date

0 - AMA / ❑DREDGE & FILL N° 77269 A C D
ENERAL PERMIT Previous permit# t'N 1r4*
)C a' ew ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued t4. },9
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 01 h4 . t 2L.)CP `
•
[Rules attached.
Applicant Name C i44at , Cake-r -E 5 Project Location: County 'Be4.-t.i '1 i-- C .
Address ] l --P-cO1 i r l "Zed . Street Address/State Road/Lot#(s)
City£ 12.- i--L V 1+-LE State 14'e-ZIP 2'-) s 6'% 3 'f 2— 1 i T-r w v'-' -T-- sz
1. Phone#( ) E-Mail Subdivision LQ 's-rA L fr PrZ..1/44
Authorized Agent 67,14A. PA-/-K...t� City-13cp v 4,4q5 - t& ZIP Z7-rts 1-7
Affected ❑f.W KEW peTA ❑ES ❑PTS Phone# ( ) River BasinTtlCL-PP 'C 0
O AEC(s): OEA El HHF O IH ❑UBA ❑N/A Adj.Wtr. Body'?A Nt..'ea -0 t VEx.... na man /unkn)
❑PWS:
ORW: yes /,moo J PNA yes no) Closest Maj.Wtr. Body �t1✓t`^1 v •Zt tJic'yl_
•
Type of Project/Activity 1.3 A - 13 u r-i c )=7L,t- 30h-5" r .ter
(Scale: it i=3 )
Pier(dock)length — .
1 - fire+ '
Fixed Platforms) } t 9 001
Floating Platforms) I 1 X ��aa�� t r -
Finger piers) -� 1 4 ✓ 3 jS +.... --{ —
Groin length ; i i rF-c v < p . . o ?Y) a if . ' t f Y77`,
number ; 1 I 134lA17 laI i _. I ; e. I 'tS31C?t0'7v -
Bulkhead/Riprap length j — {... y_.
avg distance offshore M Ll(c.3---P-) u , . .-m• iI I
max distance offshore I - } f
Basin,channel ? I j I I I L` ' '!
--Q � 3'�W; x sPi
cubic yards \ i i ' i ....watt 1 I S.
.( . it
r
Boat ramp i
...
Boatho oatl' i t 14 GOJ(MCI-- - -.-_.--_..-. -- . . ....... ...-`
I _.}i._. _rt__ ._
Beach Bulldozing 1-- -1'-_.. '
Other ? i
j 4 t -r,
i Iete 15r i"+ i I
i I 'Rv1 i.'1L1 !
Shoreline Length �'k7 i
I r -.
SAV: not sure---,yes no ,
{
Moratorium: n/a yes no i' 17 rbT, p ` ;
Photos: yes : It a a� ; i 0 � F
L.
r
Waiver Attached: . i Q "'r
A building permit may be require`d by: 171301.w.orT-s+--1-r Cc, • ee note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions • J S �dM 1 T L\t& i i 5 " i tart. 1-z> '7- 'C-iv CIO
' J/ 5L... P`' •
Agent or Applicant Printed Name Permit er's Printed N
p
Signature "Please read compliance statement on back of permit** Si atu
60
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(9 I 0-796-72 1 5)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

0 aCCAMA / DREDGE & FILL N0 77269 A B C D
GENERAL PERMIT Previous permit# lA
›v itNew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued N
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 ISA NCAC ► - " `� .
[Rules attached.
Applicant Name C 0- z1 3 64kL712-E.5. Project Location: County 13 t•ra.....--j-17, 11— (c..) .
Address ) 1--)" 0 R u r-) V k . _ Street Address/State Road/Lot#(s)
City L)T.z.iet,--r-i u i'-t.c State 14 C_ZIP 2-)c�S''A > + : 1�12- r t 1 w C.)v. 1""..t1 ,
Phone#( ) E-Mail Subdivision 2 Li s'r A-ti 1.;E R-z_i-h
Authorized Agent (it rj A 1:1"/JfZ Y-tD City TI Li rr-a-►'S C)7....,e-1L ZIP 2- ) C I—)
Affected IIICw REW ?ETA ❑ES ❑PTS Phone# ( ) River Basin'TZ A; -(9A'-'t.' r 0
❑OEA 111HHF ❑IH ❑UBA ❑N/A �,A L,O L VtYL AEC(s): Adj.Wtr. Body" (n"/man /unkn)
❑ PWS:
ORW: yes / no PNA yes no Closest Maj.Wtr. Body 74k.1`"/ c› Z1 r'y _
Type of Project/Activity '..3 _ 13 u r►e 0 v t at t y� 30k T1./ i"f'
(Scale: 1,. ; 3 6 )
Pier(dock)length
I I ' 1111.111101011 �w��1�
Fixed Platform(s) IMINIMIM—_• ! 1 _'�.�.��y f1 •�
Floating Platform(s) .,- I l I. - III
Finger pier(s) I I I IMO f.._..a. 31._._,-_. /ft.'oat: WMGroin length ! ' A .._..._._..-
number - -_—. ► -. NMI f'
I NM _
_..rt 1 _ ...___ k
Bulkhead/Riprap length _-I I I I l
avg distance offshore - ^•1 r A. 1 _IZ 1 RI1 --■11010111111.11."
max distance offshore I 1 1 11.1 I I _—••••••••••
Basin,channel MN I I —� �—
� �1�••����11111i11111M 111111�
cubic yards I .■� —�`'���•�
Boat ramp
1
1�_�� 1111111 =11•111
I ! i ' Mill
Boathouse/Boatlift- U 14 400 - .311M 1- -f-------
�► y ti t -- —,
13 ✓• _ 1� I I 1 I
Beach Bulldozing - __. •
�t �M••••
Other ■ VI =NIIIIIIIIII
IEMININII
R .13__ EIMIIIIIIMI
Shoreline Length -:-4-P-2-‘..J ' I I I 1•111��__
SAV: not sure yes no --.-----t-.-. M
Moratorium: n/a yes no )j-U4*0-n
Photos: yes -n'C"� % � t
�4
Waiver Attached: *up no --Ppv
A building permit may be required y: -i 7(U.4T-eP-l---- `c, • N"See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions I A►,S "P 1^^ ` T Lk M t-I-5 - 1 trtr I U _Z "mil x C-10
/
Agent or Applicant Printed Name Permit Offker's Printed Na
)`
Signature **Please read compliance statement on back of permit** Si atur
c�y1 t_ 4 - ° 'L2'� J '3 ���24., o/ -OW SS "2—/
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(9 I 0-796-7215)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/ 1-888-4RCOAST 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

•. CAMA
/ DREDGE & FILL N� 77269 A B C D
GENERAL PERMIT Previous permit#
>' LNew ❑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 .
E Rules attached.
Applicant Name L 0,,..4 i , .:.;'"t ,:_a -.a Project Location: County .
Address i i 7 v , r-1 '. .,,t , Street Address/State Road/Lot#(s)
City '�._..='-z �- I ,Li r State i4 ,.- ZIP -... , F
Phone#( ) E-Mail Subdivision i,= , 0 I. '
Authorized Agent J j r,' F'r\,'-K- t>L City ' , ', ,._�'tIL ZIP ;-4 ' _.)
❑CW ❑EW pfTA ❑ES ❑PTS Phone# ( ) - _ River Basin ,.'. , -i \ ( ()
Affected ❑OEA ❑HHF ❑IH ❑UBA ❑N/A
AEC(s): Adj.Wtr. Body ' ' -', %'- (natti/man /unkn)
❑ PWS: ~-> -
ORW: yes / no PNA yes / no Closest Maj.Wtr. Body ` '`' (- - •- ',
Type of Project/Activity
.. (Scale: ' - 3 o )
Pier(dock)length
Fixed Platform(s) - 1 }4A {
Floating Platform(s) r+ ; Y _
Finger pier(s) 14-�S'? 1.A ____ +_---': - I/
Groin length N i i') / • t J'' ()'.!`'t
number / -- r' ,), -��,- r.t ,ter_0%5.;Ys --
Bulkhead/Riprap length 1 -._....;....____.. --- -___. , + _........-._�.. ^_-_-----..... i , -
avg distance offshore / __ -1."► l -r'il L ,f... L.J r l t_ 1 ~
max distance offshore f
I ,
I
Basin,channel
_Y }'
•
1 —
_� ' i ��trl�
cubic yards j j
Boat ram __ 1 G -j.�. `; ) •
_.
i
p ; i 1 1 I 1
Boathouse/Boatlift ,+,-'G J‘itle - —---..___F--.__-_ - r-1- ' -+--
Beach Bulldozing t '_,i, ,y '
Other Th
I 1
( I 1
I '..-•f-•'r !.:.,
Shoreline Length -1/�-� j
I I
SAV: not sure^' yes no - y —_._.i_ __
Moratorium: n/a yes nor":trF�aFtrµr. Ilk- - - . - -
Photos: yes t1D-L ; 7.0;Wo i t -± xt
Waiver Attached: yes no; 1 I N.
I
A building permit may be required by: t t1..1 T-c.• I:-1- - . j See note on back regarding River Basin rules.
(Note Local Planning Jurisdiction)
Notes/Special Conditions x+-s , ' 'c -'ti Is. L'I!".� , ' ' -1 <"? ' -t "i L] `.. .
• - 7;''
Agent or Applicant Printed Name Permit Officer's Printed Name
Signature **Please read compliance statement on back of permit** a,Si/Q/qn"aturey_ -'' // /
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(9 I 0-796-72 15)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 910-796-72I5
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 Consent Agreement
I C ((1S 61/ -- ,hereby authorize CAI n� �CL Q.1/to act on
(Property Owner) (Authorized Agent)
my behalf in obtaining CAMA permits for the location listed below. This agency
authorization is limited to the specific activities described above.
Property Address:
147, DEtKA400 Dia
..oi n3 CL ,(C,
Zit11
Property Owner's Mailing Address:
l/ .'0S1M 14D
VeSeK
Property Owner's Signature:
Authorized Age t Signature: j8/14964/C-C
Date:
Form:Authorized Agreement as developed by NCDCM revised 9/25/06

From. Parker, Walter V [e-mail]
Subject FW: Additional boat lift at 342 Driftwood Drive
Date Sep 4, 2020 at 12:05:55 PM
To [e-mail]
[e-mail]
From: Karen Carr <[e-mail]>
Sent: Friday, September 4, 2020 11 :59 AM
To: Parker, Walter V <[e-mail]>
Subject: Re: Additional boat lift at 342 Driftwood Drive
EXTERNAL EMAIL — Use caution with any links or file attachments.
2nd try!
On Thu, Sep 3, 2020 at 12:31 PM Karen Carr <[e-mail]> wrote:
It is my understanding that there are plans to add an additional boat lift to the pier at
342 Driftwood Drive, in Crystal Beach Estates. As an adjacent property owner, I have
no objections to this proposal.
Please contact me with any questions or concerns.
Karen Carr
919-604-0255
Notice: This e-mail message, together with any attachments,
contains
information of Merck & Co., Inc. (2000 Galloping Hill Road,
Kenilworth,
New Jersey, USA 07033), and/or its affiliates Direct contact
information
for affiliates is available at
http://www.merck.com/contact/contacts.html) that may be
confidential,
proprietary copyrighted and/or legally privileged. It is intended

solely
for the use of the individual or entity named on this message. If
you are
not theintended reci recipient, and have received this message in
p g
error,
please notify us immediately by reply e-mail and then delete it
from
your system.

V
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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to C t.a2A5 t c.Srr.Z CAA LT2cSS 'S
(Name of Property Owner) it
property located at 3`1'2 Dn%c'twooD Of_ 3�„,,.;'.5 L2-t e IL i\1L
(Address, Lot, Block, Road, etc.)
onQAM.i-ioc. i-)tv�� , in i3L.c.,=�Ss - rz..cCIt , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc tion.
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
T Ac.N E n cD ' C)
WAIVER SECTION .
I understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, lift, or groin
must be set back a minimum distance of 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' setback requirement.
I do not wish waive the 15' setback requirement.
(' •pe iw • nformation) (Adjacent Property Owner Information)
,.(02-1, 6
Sig.a ure ignat e
'?TTT (tA R.l 5 Cl A LI n-c S S 1 E 12. 1 ,c)C 4-)v i3 121 S
Print or Type Name Print or Tye Name
11 1 of) ti iS 0 Y `\Lo ¢,F_;,;:D i cpzi r, 2ci
Mailing Address Mailing Address
L1n cfr.) J , Lce c -10L OAK'S T. C.- 2"1y 2—A
C't Sa / RyG�astl,pjv�tivik.✓tc� City/State/Zip
`'Z�t 1e�ZipAga( egg elect 9 3 t - `tt(1
Tel hone Number/email address Telephone Number/email address
Date Date*
(Revised Aug. 2014)
*Valid for one calendar year after signature*

t1C Division of Coastal Mgt. Habitat Impact Gasp-rater S4iee,
Applicant: C titer 5 6;2 i 1Z E 5
Date: .7 )g j-z_i)2-0
General Permit*: - 3
Describe below the HABITAT disturbances for the application. All values should match the name,and units of measurement
found in your Habitat code sheet.
TOTAL Sq. Ft. FINAL Sq. Ft. j TOTAL Feet ! FINAL Feet 1.
(Applied for. (Anticipated j (Applied for. (Anticipated anal
DISTURB TYPE Disturbance total disturbance Disturbance i disturbance.
Habitat Mame Choose One ncludes any Excludes ry total includes I Excludes any
anticipated estoratian any anticipated restoration and/or I
restoration or and/or ern restoration or temp impact
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