74615D - House

CAMA / DREDGE & FILL NO. 74615 A B C
GENERAL PERMIT Previous permit#
-New '.Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality �� / /�0 q �.y,�W
and the Coastal Resources Commissiovin n area f environmental concern pursuant to I SA NCAC �--
❑ Rule attached.,r�
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Applicant Name �� Gf C/ Project Location: County 11 S w C�
City
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State P G � ZI�j '7 /
Phone #�) �' ,6 l E-Maii
ORW: yes nod, PNA yes no
Authorized-Agen
l
✓
❑ CVH
PTA
�ES ❑ PTS
Affected
AEC(s): ❑ OEA
❑ HHF ElIH
❑ USA ❑ N/A
ElPWS:
Street Address/ State Road/ Lot s)
Subdivision
City `� �/ / l// (/� ZIP
Phone # (`---j—"'— = River Basin C'C�
Adj. Wtr. Body �44,4 a / (nat man unkn)
Closest Maj. Wtr. Body —� &z )4— �
M.
�■■■■■■■■■�■jJli(�■SIG■ill■■■■■■■■■■■■■■
read compliance st/tem'6qt on back 9LRermit �;
Application Fee(s)

AGENT AUTHORIZATION FOR CAMA PEEWIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
r)
Phone Number:
Email Address:
I certify that I have authorized
I
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:. �fi I k I07d ( �eawd `%
r t at my property located at 263 7
/1
in bnS I 0V County.
I 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 Information:
Signature
I _ Print or Type Name
Title
��
o_I�l_
Date
This certification is valid through I I

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property: j 4+) S Al c5 J
(Lot or Street #, Street or Road, City & Coun )
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 are proposing. A description or drawing, with dimensions, must be provided with this letter.
y 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
understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15from my area of riparian access unless waived by me. (If you
wish 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)
Signature
1 bwl i d -f1-O(?5 e
dint or pe Nam
4 12. r 26 11 c)
Mailing Address
Wa..r,sa w lq G 283Q g
City/State2ip
a!D - 2t4 - 1t6 Z5
Telephone Number
(Adjacegt Property Owner Information)
Signature
Print or Type Name
R2 c-7 ( kcin r1 - Twt vc,
Mailing Ad(dre�ss
Vl�(�Ji�IY.I;I.I) 14C
City/Sta e ip
-70 4 -q1 49
Telep one Number
Date Date
Revised 611812012

May 1,2019
LeAnn Blackburn
124 South Fremont Street
Faison, NC 28341
Hey Ken,
It's LeAnn from the beach (your neighbor on 71h Street). I am writing to ask if you will sign the
enclosed forms giving us permission to tear out the old seawall and dock and rebuild new ones.
I have to have your signature because the dock is within 15 feet of your property. I appreciate
you speedy attention to this request. Please fill in and sign the forms. Returning them in a
speedy manner will allow us to get started with this project right away.
I hope you are doing well. Cliff and Sharon told me you were down at your cottage during the
week of Easter. I wish had known. Hope to see you this summer.
Sin, erel
L An eRburn
Q"as--, YT nOUQ /

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to
property located at
W
-Doruld Huse ,s
(Name of Property Owner)
(Address, Lot, Block, R ad, tc.1
on �.(1(1 in N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
location.
L' I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
1�ep[co,e, seau-�a�l and caocv—
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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 i e the setback, you must initial the appropriate blank below.)
V I o is to give the 15' setback requirement.
I do not wish to waive the 15' setback requirement
(Property Owner Information)
_ ature
M;A C. t�)HOck—s+- —
'ng Address
aiQy;aw I V G
d t= t� �tl Z-- -1 4 5
Telephone Number/fir ail address
Date
(A acent Property Owner Information)
'g ture *
Print or T pe Name
1610 (�kb DY.
ailing
� I LL2g3��
WtIfft,op -IH6,3
Telephone Ngm¢OW email address
Date *
(Revised Aug. 2014)
*Valid for one calendar year after signature*

Date Received
Date De osHd
Chock From Name
Name o7 Permit Holder
Vendor
Check Number
Check
amount
Permit Number/Comments
Receipt or Retund(Reallucated
Co/umnl
Cclumn2
Column3
Column/
Columns
Co1umn6
Column7
Co1umn8
Columne
8/29/2019
_
Burle Smith Money Order
Li hthouse Marine Construction Inc.
Sherry and Phil Jacobs
BancFirst
Coastal Bank and Trust
1.83E+08
$ 200.00
GP #74814D
GP #74815D
JD Mt. 8532
JD rct. 8533
8/29/2019
Donald House
2839
e00.00