71244A_Nelson & Kaye Jones_20181031

.. ACAMA / ❑ DREDGE & FILL No 71244 B C D
' GENERAL PERMIT Previous permit#
L 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 I SA NCAC N • I I L'o
Rules attached.
Applicant Name N e t su,,,
Address I S 0 9
City k .11 Q c v .1 N % State _ ZIP a n y >'
Phone # E-Mail
Project Location: County De,
Street Address/ State Road/ Lot #(s) )b9 F{Gol1,.i �!
Subdivision
Authorized Agent W 1=
City So V I Fk r e� 5 k o t -k S
ZIP a _+c14 1
Affected ElCw ❑ EW
X'PTA ❑ ES
�I PTS
Phone # ( )
River Basin Po o } e,^ r-
AEC(s): EloEA ❑ HHF
ElIH ❑ UBA
El N/A
r c. Adj. Wtr. Body C c io Tc 9 r.
GJ.(nat / ) � c t
❑ PwS.
Closest Maj. Wtr. Body �, , r
• �� So,,,.
ORW: yes / ;fi§) PNA
rs / no
Type of Project/ Activity
Nt r . g.+�K ly.
rl M c ��t I
<, ►��J� I,✓��
(Scale: (� / J )
Pier
Fixe<
Float
Finge
Groi
�'
Basir
Boat
Boat
Beac
Oth<
Shor
SAV
Mon
Phot
WaiN
■■■■■aMEEEME�■w�■���■■������MENOMONEE
■■■■■■■■■
■■■■■■■■■■■■■■■AIRIER!!!!'■■■■//i/1f�©III/I�■■■■■■MEN
■■■
■■■■■■■■■!!�■■
MUNME\`R■bi
n
WOMM
MEEM
MEMO
cubic yards
r�EE�■■�����
ramp
ONEMEMOEMOME■■EEO■EOS�HV�
-i Bulldozing
fline Length
not sure .
■EiiiiiE■■■EEOi■MOOED■EMOEiiiii■E00■■■EE■■E
■■■■■■■■■■■■
■■■■■rA��a■■■■��■■■■■■■■■■■■■
yes;
toriurn: 6) yes no
no
_, . ..
mr,..
M
■EEO■
■■■�■
■■■■■■■■
■1�■■
■■■M
■■■■
■■■■����■■■■■E■M■M■■■
■1�■■E■■■M■■■■
A building permit may be required by: sp,1t }.. Shyl t
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Ie_ Erxno�:n
(Agent -Applicant Printed Name
F,
Sig ature J "Please read compliance statement oAackofpermit"
A LAD& o3 a y S $-+
Application Fee(s) Check #
❑ See note on back regarding River Basin rules.
Name
Signature
ITJ,4019 3/, )aD)Ci
Issuing Date Expiration Date

NC Division of Coastal Mgt. Habitat impact Computer Sleet
Applicant: Jug *),
Date:
Permit #: 7
Describe belok�r the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat 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
S ,
Dredge ❑ Fill Both ❑ Other ❑
Dredge ❑ Fill Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ElOther ❑
a g o
a
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 ❑
252-808-2808 :: 1-888-4RCOAST :: www.nccoastalmanagement-net revised: 02/03/10

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date ID12-9116
Name of Property Owner Applying for Permit:
/q Hsu ; . 604-,5��
Mailing Address:
I certify that I have authorized (agent) 9Q-T �fSf%-k� to'4A4C— to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) 1614 C- '
at (my property located at)
This certification is valid thru (date)
Property Owner Signature
gj�-
l Z-q/4
Date

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
9590 9402 3871 8060 8626 50
A. Signa
X
B. Wceived by (Printed Name)
A
C. Dgte of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ONo
3. Service Type
❑ S' C fl ti
❑ Priority Mail Express®
❑ Adult Signature
❑ Registered MaiITM
❑ Adult Signature Restricted Delivery
❑ Registered Mail Restricted
PILCertlfied Mail®
Delivery
❑ Certified Mail Restricted Delivery
0 Return Receipt for
❑ Collect on Delivery
Merchandise
T*r
2. Artinlca Ni trnl /Transfer from service Jabal) ❑ Collect on Delivery Restricted Delivery ignature on rma on
Signature Deli
7 018 0680 0001 5647 0595 rioted Delivery Confirmation
Restricted Delivery
PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Return Receipt

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
L . Cod 1
III�IIIII III'll ll ( II IIIIIIIIII II (I III
9590 9402 3871 8060 8626 67
A.
Agent
Received W (Printed Name)
Is deI@1e ad different 6m- item 17 ❑ Yes
If YES, enterWelivery address below: J, No
3. Service Type
❑ ti
❑ Priority Mail Express®
❑ Adult Signature
❑ Registered MailT1
❑ Adult Signature Restricted Delivery
❑ Registered Mail Restricted
Certified Mail®
Delivery
❑ Certified Mall Restricted Delivery
❑ Return Receipt for
❑ Collect on Delivery
Merchandise
TM
2. Article Number (Transfer from service 1abep ❑ Collect on Delivery Restricted Delivery Signature Confirm- on
❑ Signature Confirmation
7 018 0680 0001 5647 0588 cted Delivery Restricted Delivery
PS Form 3811, ,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt
I

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERED
Name of Property Owner: 1
Address of Property:
(Lot or Str #, Street or Road, City & County)
DRRL
Agent's Name #: N(;— rle Mailing Address: POBo- 4a-
Agent's phone #: a5a -;4 I -31osa u t t� C '
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 must be provided with this letter.
I have no z jections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Correspondence should be mailed to 401 S.
Griffin St., Ste 300, Elizabeth City, NC, 27909. DCM representatives can also be contacted at (252) 264-
3901. 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, 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�w)vph to waive the setback, you must sign the appropriate blank below.)
i
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
`jILUV) TO ne�5
Print or Type Name
) Zx 0-anho --s Ly---)
Mailing Address
I 6 11 rev i k On Its , N C, 2'14 qi�
C00ate2ip
gc53-Q0—g,33 �3
Telephone Number/Email Address
101 P)
Date
(Adjace � Property Owner Information)
Si na�eall
re
Le 1� �r, w� v►
Print or Type Name
Mailing Address
����H �1�3 fit/G Z� `� t-f 9
City/State2ip
Telephone Number % Email Address
Date* 1
`Valid for one calendar year after signature*
Revised 2017

�0
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
CERTIFIED MAIL - RETURN RECEIPT REQUESTED or HAND DELIVERED
Name of Property Owner: NJ V 1;
Address of Property: I (CI I
(Lot or
Skub ) -TCneS
, Street or Road, City & County)
Agent's Name #: �JE M(�? n(�- Mailing Address: PO
Agent's phone #: -) S -)( - 3(A D fit,
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 dravving. with dimensions must be provided with this letter.
6U �.r'
S�,ll � n�pn2�
I have no o jections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you must notify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Correspondence should be mailed to 401 S.
Griffin St., Ste 300, Elizabeth City, NC, 27909. DCM representatives can also be contacted at (252) 264-
3901. 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, 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 sign the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner information)
Signature
S LE �(Dnr
Print or Type Name
15o,(6 In
Mailing Address
611 Dcv+ 1 �b
City/Stat&Dp
- �333T ,
Telephone Number / Email Address
lo
Date
(Ad'a i F`ope Owner hSformation)
Sim ture
Print or Type Name
Z J 7.3_J/6 u-`( —7e-lq/L
Mailing Address
tee. r�orL ssr 0 , C. Z -7 Q L49
City/StateTZip
25 Z p 40 &1 � 3 r-01111[�l FM 6A4fP
Telephone Number/E_mail Address t✓IgIL'.&rt.
1D-/o,16
Date*
*Valid for one calendar year after signature'
Rev1sed 2017

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