21090_LEFLER, KEITH_19981124

CAMA AND DREDGE AND FILL'If M
GENERAL sc? OU1190
PERMIT
as authorized by the State of North Carolina
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15A NCAC
Applicant Name Phone Number G��-�
Address
City State Zip
Project Location (County, State Road, Water Body, etc.) 7V s.:r_`•{2 l z i �_-
Type of Project Activity
PROJECT DESCRIPTION I SKETCH a C.(� . k. . r-
Pier (dock) length
Groin length
number
Bulkhead length
max. distance offshore
Basin, channel dimensions
cubic yards
Boat ramp dimensions
Other
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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,
imprisonment or civil action; and may cause the permit to be-
come 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 1) this pro-
ject is consistent with the local land use plan and all local
ordinances, and 2) a written statement has been obtained from
adjacent riparian landowners certifying that they have no
objections to the proposed work.
(SCALE:
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applicant's signature
permit officer's signature
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issuing date expiration date
attachments ( :! Ff i �1 i
In issuing this permit the State of North Carolina certifies that f CII NO, L.l l j
this project is consistent with the North Carolina Coastal application fee FLa -I.+ D `7 tom; . 1�F3�
Management Program.

LINDA OR WAVERLY D. SHORE
DBA PAMLICO MARINE CONST. c� G 11
HER NCDL 4789098 HIS 3266479 L �---(---------19-9a-
PH.919-745-7992 66-7796/2531
-_. P.O. BOX 163, DIXON RD.
VANDEMERE, NC 28587
PAY TO THE O
ORDER OF
Q1%� t � �1✓� �- b' -tii _ _ NC O/I e) 0
Winston-Salem NC
MEMO
1:253 L779681: 00 L?4Q611' 6 19
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nt Riparian Property Owner Statement
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SIGNATURE
I hereby certify that I own property adjacent to ktrj
Name of landowner proposing development
on in/near Lot# of
Community
Tax Parcel# off SR
Complete description of how to locate this property
Subdivision, if applicable
This proposed project, a S1,11 !S AaO and the location has been described to me as
shown in the drawing below and I have no objections to the proposal.
For a Pier, check the Following:
I wish to waive the 15' minimum setback from my riparian access
I do not wish to waive the 15' minimum setback requirement.
Draw the proposed structure in the space provided below. List the size of the structure and
measured distances from the adjacent property lines, other structures on the property, and the
road. water, etc.
I
After this form is completed by the landpwner proposing the project, a copy is given to the adjacent
landowners for their consent and signatures. The forms are then returned along with a building plan
and other applicable required information to the Building Insp. Office for building permit application/
processing.

P 405 993 521
Receipt for
Certified Mail
No Insurance Coverage Provided
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(See Reverse)
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P. ., State and ZIP Code
Postage
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Certified Fee
Special Delivery Fee
Restricted Delivery Fee
Return Receipt Showing
to Whom & Date Delivered
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Return Cld-441hom,
Date,. d8iessee's Palo
TO ostage
& 2P5
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P 405 993 530
Receipt for
Certified Mail
No Insurance Coverage Provided
Do not use for International Mail
(See Reverse)
S o J
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Street
d No.
P.O , State and ZIP Code
N�CA
Postage
Certified Fee
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Special Delivery Fee
Restricted Delivery Fee
Return Receipt Showing
to Whom & Date Delivered
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Return Rec
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Date, a c�„A
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(1SPS

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O . ■Complete items 1 and/or 2 for additional services.
m ■Complete items 3, 4a, and 4b.
N ■ Print your name and address on the reverse of this form so that we
card to you.
y ■ Attach this form to the front of the mailpiece, or on the back if spat
d permit.
y ■ Write -Return Receipt Requested' on the mailpiece below the article
« ■The Return Receipt will show to whom the article was delivered an
( C delivered.
Article Aaaressea to:
Doru ld Lee- & J larA
PO 8©K'545
�e.rNe,rsville NC
e
I also wish to receive the
following services (for an
can return this extra fee):
ai
does not 1. ❑ Addressee's Address j.
number. 2. El Restricted Delivery
d the date
Consult postmaster for fee. m
4a. Article Number a,
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4b. Service Type
i ❑ Registered UY Certified Cr
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❑ Express Mail ❑ Insured S
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❑ Return Receipt for Merchandise ❑ COD
7. Date of Delivery
(Only if requested
>ignature: (Addressee or
X
and fee is paid)
PS Form 3811, December 1994 Do
4a. Article Number a,
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cc
4b. Service Type
i ❑ Registered UY Certified Cr
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❑ Express Mail ❑ Insured S
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❑ Return Receipt for Merchandise ❑ COD
7. Date of Delivery
(Only if requested
>ignature: (Addressee or
X
and fee is paid)
PS Form 3811, December 1994 Do
(Only if requested
>ignature: (Addressee or
X
and fee is paid)
PS Form 3811, December 1994 Do

UNITED STATES POSTAL SERVICE
First -Class Mait
Postage &'Fees Paid
USPS
Permit No. G-10
• Print your name, address, and ZIP Code in this bak

ADJACENT RIPARIAN PROPERTY OWNER STATEMEENT
(FOR A PIER/MOORING PILINGS/BOA?ZIFT/BOATHOUSE)
4
I hereby certify that I own property adjacent to 4 s
(Name of Property Owner)
property located at 7 �� 6 ; v c llc ')'y . G,9,✓ rw
(Lot, Block, Road, etc.)
on Ali lllt:�l in d
(Waterbod) , N.C.
Y (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 set back a minimum distance of fifteen feet (15') from my area
of riparian access unless waived by me.
I do not wish to waive the setback requirement.
I do wish to waive that setback requirement.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
L; ✓ l a /�'t s„
Signature
Print or Type Name
Telephone Number
Date:

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual applying for Permit:
Address of Property:
4,--1 yw' w a 2, V 0 �
(Lot or Street #, Street or Road, City & County)
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawing the development
they are proposing. A description or drawing, with dimensions, should be provided with this
letter.
I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coastal
Management, Hestron Plaza II, 151-B, Hwy. 24, Morehead City, NC, 28557 or call (252) 808-
2808 within 10 days of receipt of this notice. No response is considered the same as no objection
if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house, lift or sandbags 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.)
Signature
Print Name
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
Date
Telephone Number With Area Code

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SENDER:
■Complete items 1 and/or 2 for additional services.
I also WISh t0 receive the
W
-Complete items 3, 4a, and 4b.
following services (for an
1 0
■ Print your name and address on the reverse of this form so that we can return this
extra fee):
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card to you.
■Attach this form to the front of the mailpiece, or on the back if space does not
1. ❑ Addressee's Address
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y
permit.
■ Write'Return Receipt Requested' on the mailpiece below the article number.
2. ❑ Restricted Delivery
N 1,
.t.
■The Return Receipt will show to whom the article was delivered and
delivered.
the date
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Consult postmaster for fee.
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3. Article Addressed to:
4a. id Numb _
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4b. Service Type
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❑ Return Receipt for Merchandise ❑ COD
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7. Date of Delivery
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S. Received By: (Print Name)
8. Addressee's Address (Only if requested
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and fee is paid)
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6. Signatu : (Addressee or Agent)
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PS Form 3811, December 1994
Domestic Return Receipt

UNITED STATES POSTAL SERVICE First -Class Mail
Postage &Fees Paid
USPS
.. _ : _.:..: •- _: -: �.: •..:':�:: ^ :.: .: w:: ::.-. t'ermit No. G-10
• Print your name, address, and ZIP Code
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