Clifton, Vickie

❑ CAMA / ❑ DREDGE & FILL No. 74960 A B C D
GENERAL PERMIT Previous permit#
ONew ❑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
©-Rules attar ed.
Applicant Name ) f pp 'r^ k � C � � i Project Location: County : i.
Address / ~ Street Address/ State Road/ Lot #(s) l/
City , L State ZIP
Phone # ( ) , )W/ E-Mail Subdivision
Authorized Agent
Affected ❑CW 1p.EW _[PTA DES ❑PTS
AEC(s): DOEA ❑HHF ❑IH ❑UBA ❑N/A
❑ PWS:
ORW: yes./ no': PNA yes /, too.
City ZIP
Phone# O River Basin inn*l<
Adj. Wtr. Body >:" / �— (nat)/man /unkn)
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Closest Maj. Wtr. Body ` ` E ' - .. ,
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Agent o�Printed Name
SignaturPlease read compliance statement on back of permit**
Application Fee(s) Check#
/
Permit Officers Panted Name
Signature /
Issuing Date Expiration Date

I hereby certify that I own property adjacent
property located atc�cpri LXwf1m E
/j//2 7Q (Address,
(Waterbody)
N
and/or County)
N.C.
The applicant has described to me, as shown below, the development proposed at the above
too tioy�.
�./ I have no objection to this proposal.
-- .-_-_ I have. abjectionsto_this_proposal. _
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
WAIVER SECTION _
I understand that a pier, dock, mooring pilings, 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 to waive the 15' setback requirement.
(Property Owner Information)
r0,
(Adjacent Property Owner Information)
4 � y.
Telephone Number
& -If- I S
Date
AA*
(Revised 611812012)

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
- ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAIVER FORM -
Name of Property Owner:
Address of Property: 3 0
(Lot or Street #, Stre t or Road, City & County)
Agent's Name #: Mailing Address: V I
Agent's phone #:
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 drawlnXjhe development
they�ze
ang•A sonodaand>vih
c)iretensions'rnustb�irolefith1C1I`etfe.
no objections to this proposal. I have objections to this proposal.
If you have objections to what Is being proposed, you mustnotifythe Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Correspondence should be mailed to 400
Commerce Ave., Morehead City, NC, 28557. DCM representatives can also be contacted at (252) 808-
2808. No response is considered the same as no objection if Lou have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, 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
r ri-
(Property, O nformation)
i e
S 5 -_
Print or Type Na e
Mai ing Address
Telephone Number
Date
requirement.
(Adjacent Property Owner Information)
Signature ell
JIGK �f� kd, L BOA%
Print or Type Name
a9 .rADM6 a&
Mailing Address
, )L0 4L�a � �a
/Stateli
L � 14-1 A
Telephone Number
&/ag 19
Date
Revised 611812012