73510D - Assell

V CAMA / XDREDGE &FILL INTO, '_�]3SIO
GENERAL' .PERMIT_. Previous,permit #
New ❑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
{ F-1 Rules attached.
Applicant Name WILLi*t& A CC' i�i 1—Tew .55iiiL. Project Location: County,' RtA Js,.,f ctc
Address c/lob SNAc>pwRAr p_w_ StreetAddre// Address/ State Road/ Lot #(s)
..-City-,-MAVryA .1�5 ' State ZIP. � S .VO —i Z4A DTZ.1ym
Phone_# (Gigs) �55 - 9z72 E-Mail W.ef`� hai l,eor, Subdivision n!%
Authorized.Agent, i t L.MS City I.®Ex✓ cm ZIP
XCW ❑EW❑PTA ;(ES KPTs GV_rtc Phone # (916) 445,-. 4-919 River Basin "Lt� �,y_P,,
Affected '
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Agent or_Applicant P-riin-tted Na—e
Signatures *eplease read compliance statement on back of permit
Application,Fee(s) Check #
Permit Officer's Printed " ame ;
c-
Signature
Issuing Date Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address: G`r70
ov oL4 . .
Phone Number: q �Co- 3sS
Email.Address: W • a ss�11 @ �pr}i►�c► ; - . aM
-- -I certifyY -thatl have- authorized ZA 4'.—) ,"' s — - —
Agent / Contractor_
to act on my behalf, for the purpose of applying for and.obtaining all LAMA permits
necessary, for: the following proposed development:
and dock �e.pa
at my property located at 1`I g �Jna ®� Wolde� i3etich DJc a;K6a
in: (3r-��s,���)c County.
furthermore certify that l am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit. Officer and their agents to enter
on the _ aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Inf ma ' n:
Signature .
tj
Print or Type Name
Title
-
Date .
This certification is valid through 10

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION[WAIVER FORM
Name of Property Owner: lAr 1f)k,1 !16e 1 1
Address of Property: IN Tun0. Cyr. HDlCIe11&c 1;,; BrZ nsL, iGl�
(Lot or Street #, Street or Road, City R.`•z;ounty)
Agent's Name #: �(,1��Y Muinc C6r6S . Mailing Address: 016 X / I?
Agent's phone #: q IO-gg3— gR61 $ lnp &j " NC agZ1� �
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, w#h dimensions;, mGst be pr©vided if hts. etter.
ONave no objections to this proposal. I have objections to this proposal.
fir
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. Contact information for DCM offices is
available athttpJ/www.nccoastalmanagement.net/web/cm/staff-listing or by calling 1-888-4RCOAST.
No response is considered the same as no objection if you have--=';een notified by Certified Mail.
WAIVER SECTION
understand that a pier, dock, mooring pilings, boat ramp, bre4_!kv,.,ater, boathouse, or lift must
be set back a minimum distance of 15' from my area of riparia: i r;::cess unless waived by me. (If
you wish to waive the setback, you roust initial the appropriate "-ank below.)
a,l %�I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property JOw�ner Information)
�-C.�ACLYI
Signature
T z lm.s - r�t.�
Print or Type Name
l rtv7
Mailing Address
cSu 301y , Ne a ct
City/ rate ip
Q / o - LAM— 4/998'
Telephone Number/Email Address
2�2.Z�lq
Date
(Revised Aug. 2014)

CERTIFIED MAIL -.RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
- ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: lA r In il— e <
Address of Property: I LA ra nlr . Holden &-aCb.B ronSUJi GK-
(Lot or Street #, Street or Road, Ci y R ;ounty)
Agent's Name #: �� kY OdAne CbIIS�. Mailing Address: �Q01% �I ALI 99 -
Agent's phone #: q 10-40— Y Rq k NCB 29q(v 9—
I hereby certify that I own property adjacent to the above ;ferenced property. The individual
applying for this permit has described to me as shown on the att,Iched drawing the development
5 r>;
the are proposing. brovlded;�his.letter.
°.have no objections to this proposal. I have objections to this proposal.
t�Lc e'
If you have objections to what is being proposed, you must noiify the Division of Coastal Management
(DCM) in writing within 10 days of receipt of this notice. Contact information for DCM offices is
available at httpJ/www.nccoastalmanagement.net/web/cm/staff listing or by calling 1-888-4RCOAST.
No response is considered the same as no objection if you have...!een notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, br&-)kv pater, boathouse, or lift must
be set back a minimum distance of 15' from my area of ripari%i r, :cess unless waived by me. (If
you Amh to waive the setback, you must initial the appropriate r. ank below.)
. , 'I do wish to waive the 15' setback requirement.
h� re I Flo not wish to waive the 15' setback re, '` -iment.
(Property Owner Information)
Signature --
Print or Type Name I
KiekQ
Mailing Address
City/. tate ip
q / 0 - LA8— !ZZyr
Telephone Number/Email Address
Date
pari,;-n Propq-qy Owner Information)
(Revised Aug. 2014)

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Dote Received
Date Deposited
Check From (Name)
Name olPermlt Noldar
Vendor
Check Number
Check
amount
Permit NumbeNComments
Recel t or Rerund/Renitocated
Column!
Column
Cotumn3
Column<
Columns
Column6
Column?
Column6
Column.
MW019
Backwater Marine Construction lx.
WlFam and Kdsten&—fl
BBBT
11d0
d00.00
GP #73510D
TMc rct. 7380