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--. XCAMA / XDREDGE & FILL No 72315
GENERAL PERMIT Previous permit# A B C
KNew -Modification -Complete Reissue El 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 6114, 1100
^ - [I Rules attached.
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Applicant Name f oscs r & Ay C oiw_ / Project Location: County fitsL4S141 CK
Address PO 13cq( 545 Street Address/ State Road/ Lot #(s) ' S? (1-01
City A906oD State ZIP 2 i 2 M AR LI.4 T—) V.1V IG
Phone # E-Mail rob b i c G coven cc n stn4clran Subdivision N I A
Authorized Agent /.l/A Co. Cori City NOV'DG/d SAAS 1 ZIP
Affected )(CW ❑Ew El PTA XES XPTS Phone # ( ) River Basin I_(AKWEe
AEC s : ElOEA ❑ HHF Elj. Wtr. Bod L nat (IH ❑ URA ❑ N/A AdCANA
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ORW: yes / no PNA yes / no Closest Maj. Wtr. Body AWN
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Signature ** Please read compliance statement on back of permit **
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Application Fee(s) Check #
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Permit Officer's Printed Name
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Signature
1013 /.2011 z / 3�2010
Issuing Date _ Expiration Date -

QCAMA 1 DREDGE i FILL
GENERAL PERMIT
New ❑Madlfication [_lComplete Reissue E- Partial Reissue - --
N272315 A
Previous permit #
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 © r% N . %� 00
❑ Rules attached.
Applicant Name�-p ,��_ ,L/ _ Project Location: CountyRAI�>�+� CK
Address .545 Street Address/ State Road/ Lot #(s)_1
City_ _ oRW O oD State C ZIP B'r z H A IPIL L IA Ditty 6.
Phone # C 0") +3t'-2460 E-Mail Subdivision NI A
Co . CovM
Authorized Agent City__- ZIP ;z 84&z
Affected XCW OEW = PTA %ES )iPTS Phone # (____ )__-_ River Basin LtttM ___
AEC s :. 00EA ❑ HHF D IH ❑ U13A ❑ WA
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1013 %019 _ 3 ,ZoZo
IssuingDate -Expiration

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CERTIFIED MAIL • RETURN RECEIPT REQUESTED M
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN P PERT11Y OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: C t .4,
A k,: ,
Address of Property: na� lq ihlk(. ^ 110 We^ �VALCA
(Lot or Street #, Street or Road, City & County)
Agent's Name #: Mailing Address: r ' d' � oK J 4 �—
Agent's phone #: o f -s.) e o V3 c e? I Z 2'
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 objections to this proposal. I have objections to this proposal.
H you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in
wrfting within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wilmington, NC, 28405.3W. DCM representatives can also be contacted at [phone]. 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, boathouse, lift, or groin must b e6n
back a minimum distance of 15' from my area of riparian access unless waived by me.�l�y0
wish to waive the setback, you must initial the appropriate blank below.) /�;•y C n
I do wish to waive the 15' setback requirement. C
I do not wish to waive the 15' setback requirement.
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Type Name
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Te/epho a Nu r
(Adjacent Prtoperty Owner Information)
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Print or Type Name
y?22- 51tLi,
Mailing Address
Grty/StateOL
Telephone Number
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CERTIFIED MAIL - RETURN RECEIPT REQUESTED IA A.
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PIRPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: ---1K v be r + c4 ( 'rn �.v —
Address of Property: D IR l edA-r' 4t- I�n �n.sc,n �cJas.a
(Lot or Street #, Street or Road, City & County)
Agent's Name #: Mailing Address:?. • 6 • o Y J 4
Agent's phone #: rJ o f b o 0 C p t z
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.
VI 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 127 Cardinal Drive Ext,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. 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, boathouse, lift, or groin must be&n
back a minimum distance of 15' from my area of riparian access unless waived by me ltA
wish to waive the setback, you must initial the appropriate blank below.) 4;�y
I do wish to waive the 15' setback requirement. mot : P,
I do not wish to waive the 15' setback requirement.
(P
rint Qr Type Name
Maili g Address
City/State,Zipp
Telepho e 7er,
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acent Property Owner Information)
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Print or Type Name
Mailing Address
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City/State/Zip
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Telephone Number
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Date Received
Data Depowted Check From Name
Name of Permit Holder
Vendor
Check Number
Check
amount
Permit NumbenLomments
Receipt or RefuMiReallocated
Columnl
Co1umn2 Co/umn3
ColumM
Columns
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Column7
Column8
Co1umn8
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