71813D - Havlichek

ElCAMA / ❑ DREDGE & FILL 'C 116,2No 71813 A B C D
�ENERAL PERMIT Previous permit#
ew ❑Modification []Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality I 1 1 J
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
' ElRules attached.
Applicant Name L� (/ 11 Project Location: County i) .��/1jil��
Address 9 LA J Street Address/ State Road/ Lot #(s)
Ci State (' ZIP b `'
Phone #) 01'E_Mail
Subdivision 1
Authorized Agent Y City �. l' ZIP
Affected ❑ CW PTA S ❑ PTS Phone # ( ) River Basin
AEC(s): ElOeA ❑ HHF ElIH ❑ URA ❑ N/A V
❑ PWS:
ORW: yes ,% no ) PNA yes / no
Type of Project/ Activity
1 v I
Pier (dock) length
Fixed Platform(s)
Floating Platform(s)
Finger pier(s)
Groin length
�auwber
Bulkhead/ Riprap length 21 X
avg distance offshore
max distance offshore
Basin, channel
j
cubic yards
Boat ramp
Boathouse/ Boatl'
Beach Bulldozing " V--�
Other v-
Shoreline Length _T /_ 10
SAV: not sureyes
Moratorium: n/a yes
Photos: yes ne
Waiver Attached: yes no
A building permit may be required
( Note Local Planning jurisdiction)
Notes/ Special Conditions
Agent or Applicant Printed Name
Signature * Please read compliance statement on back of permit **
Application Fee(s) Check #
Acil. Wtr. Body 1 ' nat man nkn
v Closest Maj. Wtr. Body � iy
❑ See note on back regarding River Basin rules.
Perr�tAf icer s P ' ama�
Signature �
l
Issuing D e Expitatiate7

`
HCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory John E. Skvarla, III
Governor Secretary
N.C. Division of Coastal Management
AGENT AUTHORIZATION FORM
Date: O (9
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
_7- ,t.y NOX11"(4e c 'V O r/C )q azc f-
Owner's Mailing Address:
60 � F ✓ach +
a
d yqk �JC"q 2n 0-;Ls c
Email
Phone (30q 6 (02 — 00 BIZ
Agen 's Mailing Address:
�� fox 803
ORk -xi-cmko Ne• a9yOs
Email:
Phone ( % ) .2, 00 ^ ! -�? Y,3
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for, and obtaining all CAMA Permits necessary to install or construct the following (activity):
For my property located at Gs C Kcichi r-
di�LD /JC -2SY0�S
This certification is valid 1 year from (date)
hL.- I 7J, /,--Z/ 0112- /1 ri
Pr perry Owner Signature Date
127 Cardinal Drive Ext., Wilmington, NC 28405
Phone: [phone] FAX: [phone] Internet: www.nccoastalmanagement.net
An Equal Opportunity 1 Affirmative Acton Employer

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
�-� Lf-LC -bF
Address of Property: d Od �Q C '� �r . (0,qz (Cq*p /� —C ).
(Lot or Street #, Street or Road, City & County)
Q., Qor PD3
Agent's Name #: 2ayl- >�C8�- Qf Mailing Address:
Agent's phone #: 7l d o;ad -/Ay3 (nf k --rd'G)4Lo LkIC 8yG
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.
N i '1tAcf.�.
7,*h ey- 0/ 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 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 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.)
,-IrQL I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
l¢��v lip
Print or Typb Name
060 R &C�f
Mailing Addres
D � , -Eb �4 0� a
City/State/Zip
364- �/Z -ooS;-
Telephone Number
7113 �i 9
(Ad'acent Property Owner Information)
Signature
Chvi s�7v1� �-. G �► n
Print or Type Name
J 9�pelse6-r--ouv-4-
Mailing Address
- ro( ve V 5 o ; I Lt A D -24
City/State/Zi,
Ll �0 - -,;5-7 5 ,eq r (o
Telephone Number
Date
Revised 6/1 &2012

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
1t,(Lc -bF
Address of Property: ��b QC h �r - LAIC _4fC,9k,0 1QC c S 4CS
(Lot or Street #, Street or Road, City & County)
Tr
�/ �G sor
Agent's Name #: 2222f-j� ��-- Q1 Mailing Address:
Agent's phone #: 0e) - /ay3 19. d'L)C�v ,�C C-.? 8yG S
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.
-,*Atev 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 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 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.)
;L I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Si��gnaturel
R#Waillickek
Print or Typb Name
060 R C,
Mailing Addres
City/State/Zip
364- 4l2 -oo g;-
Telephone Number
�-b3 b
Date
(Adjacent Property Owner Information)
Signature
S,te f w 1�1,Jh✓A S
Print orType Name J�
711/IO0(eG 1 2 ,. /,� Z5 &, ,-/
Mailing Address
C'la k
City/State/Zip
Telephone Number
2/, 3/., -1
Date
Revised 611812012

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Date Received
Date Deposited
Check From (Name
Name or Permit Holder
Vendor
Check Number
Check
amount
Permit NumberlComments
Receipt or Re/und?tealkxated
Columnl
Column2
Column3
Column4
Columns
Column6
I Column?
Column8
Column9
/42019
H.— M. HaNichek
H. H.Aic k
MVB ank nt.
3911
400.00
P #71813
Tm 0229