73557D - Gibszon

CAMA / 'DREDGE & FILL (` ��� NO. 73557 A B C
q-EN ERAL PERMIT Previous permit #
ew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality 7 O
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC f�
n Rules attached.
Applicant Name;?�,W�y �� G /✓
Address
CitySiPA State['yC ZIP 2
Phone # %D lal9 E-Mail
Authorized Agent
Affected ❑ Cw SeEw PTA ,VEs ❑ PTs
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
ORW: yes /& PNA (ye!// no
Project Location: County PE,N � Cc
Street Address/ State Road/ Lot #(s)
5:e/V6'
Subdivision
City
ZIP
Phone # ( ) River Basin V✓,j, )F
Adj. Wtr. Body,✓- e91719d P C&26 AL (nat Lr�li%/unkn)
Closest Maj. Wtr. Body 09/ k/W
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Signature* ,Please read compliance statement on back of permit
ol" — # FLY-3
Application Fee(s) Check #
T e 6eA L►// Z Jra -
Perm(iittOfficer's Printed Name
Signature
�X�h �
Issuing Date Expiration Date

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: SA&-y PF,Je eve
Address of Property: %l �lA�%nD M. gA#y 5�
(Lot or Street #, Street or Road, City & County)
Agent's Name #:
Agent's phone #:
Mailing Address:
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 ar 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.
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 Ert.,
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 set
back a minimum distance of 15' from my area of riparian access unless waived by me. (If you
wis ive the setback, you must initial the appropriate blank below.)
,7 I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(PropepMwner I
o ation)
tgnature
Print or Type Name
&F ArA-11,1,Q�DDQ
Mailing Address
AMOS�
,c/ C. �k 3
City/St te2ip
9/0--a70
Telephone Number
Pt
(A ' ce Pro rty Owner Information)
AJ�,
Signature
Print or Type Name
%,\ NPkwiC
Mailing Address
*3�
City/State/Zip
N C -
Telephone Num er
3 I, I \5
Date
Revised 6/18/2012

CERTIFIED MAIL • RETURN RECEIPT REWESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property: /0,> e64 10 AN [6
(Lot or Street #, Street or Road, City & County)
Agent's Name #:
Agent's phone #:
Mailing Address:
Cc.
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.
If ?I have no objections to this proposal. I have objections to this proposal.
uhave 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 Ert.,
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 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.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Props wner rmation)
igrtature
�rAS 41136,0,el
Print or Type Name
f o ? �lA�l,o ,d42
Mailing Address
City/St elZip
Q'/D a/-Vr-.f y9
Telephone Number
D
(Adjacent Property Owner Information)
Si tore
Print or Type Name `
i 07
Mailing Address
5ity/State1Zip
9) o — 39t,0--,;J5 6s
Telephone Number
Date
Revised 611812012

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Date Recelvad
Dafe De alted
Cheek From Name
Name of Penult Holder
Vendor
Check Number
aChetkmount
P®mH NumbwCommenta
Recel t or Relund4Raagocatod
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