Faulkner, Evelyn Allison

^ EICAMA / DREDGE & FILL No. 74412 A B C ? D
Y/± ENEL PERMIT Previous permit#
i®j \New ❑Modification ❑Complete Reissue `❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality ! JlJ
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
r// f'�]-� ( ❑Rules attached.
Applicant Name (�Un I r�� Y; i l l ,}��I� Project Location: County
City i (� State ZIP
Phone #(3�c�fi'� E-Mail
Authorized Agent
Affected LlCW DEW CI PTA P(Es ❑PTS
AEC(s): 00EA ❑HHF LIH ❑USA El N/A
❑ PWS:
ORW: yes / no PNA yes / no
Street Address State Road/ Lot #(s)
Subdivision
city (� ZIP
Phone #Rim Bnin
Adj. Wtr. Body _ (nat /man /unkn)
Closest Maj. Wtr. Body— __ -
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Agent or Applicant Printed Name
Signature '• Please read compliance statement on back of permit" Signature
Application Feels) Check# Issuing Date
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RECEIVED
APR 0 5 2019
DCM-MHD CITY

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER-NOTIFICATIONfWAIVER FORM -
Name of Property Owner:
Address of Property:
Agent's Name #:
(Lot or Street #, Street or Road, City & County)
Mailing Address: 4103 (1" Point led
I hereby certify that 1 own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached drawingthe develo merit
they are proposing. %990 `f rot olx00
rn;
I have no objections 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 400
Commerce Ave., Morehead City, NC, 28557, DCM representatives can also be contacted at (252) SOS -
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
wI&h 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)
a
Signature
�Cy`IyN,A)I sm t4 1121
Print or Type Name
q' o &�aj �ol of
Mailing Address
YHodvdvaj
Cify/State ip
Telephone Numb r
31', 7i g
(Adjacent Property Owner Information)
Signature
.7-ref�gl,_,p m:
Print or Type Name
Go,zA 4 >Rt. R D
Mailing Address
)nori,E�NEA(_� CTM .tJc. 2SS.S7
City/State2ip
-2-7-,'-L-r�23
Telephone Number
RECEIVED
AC
Date
D
DCM-MHD CITY

r CERTIFIER BWL • RBTt aN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
I iACEiVT'RiPARtAN PROP ER.'CY-OWN,R'N'a3 i.GAi'10Nff lVEi%RORM:,
Name of Property Owns
Address of Projerty:
Adenrs Name # Mailing
Agent'sphone #. __
I hereby certify that I
applying for this perm
they are -proposing.
to the above referenced propert
The
I have no,objecttons to #his proposal. I bave.objections to this proposal.
WAIVER SECTION
I understand that a pier,. dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
batik a minimum distanoe of 16' from my area of riparian access unless waived by me. (if you
N h to waive tho'aet6ack you plash foitlal the appropriate blank below.)
th 0.0' wish to waive the-15'setba�ceteguirement.
I.do not wish to waive the 15' setback requirement.
(p/jrr�opp�ertyOwn+#rtnfolvnationr)(_ jacentpropert 7w..�or4mtlon)
Sigitiltxrpe
+ctr AJ 1 i$u�l P.
fa r+.e te, 5
Print or Type Mame Print or 7ypa Name
POI fif
.. .POBaX 1��51
MatTing Address Ma,Ylrig Address
,�� .55� New. rn ht.
dJ_V �fai'e ly ,
Telephone Npmber 7etephotwNamber
-:2-9 -
Dale Dime - ...
ZO/ZO 3Wd
Revised 6/1 2012
VillIdvil ON-V* 9OL99ZLZ9Z 9Z:V6 660Z/69/SO
RECEIVED
APR 0 5 2019
DCM-MHD CITY