74614D - Jacobs

CAMA / DREDGE & FILL NO. 74614
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GENERAL PERMIT Previous permit#
NeW Modification El 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 I SA NCAC 674 ` - !Z 00
""��) j/ ElR�ulf attached.
Applicant aLe I ( be_ 0 s Project Location: County
Address 7 2 J 'eA' Y1 • Street Address/ State Road/ Lot #(s)
City 'V I(-, AA State IV6 ZIP '-'4y-- I
Phone #` L )C f-7
Authorized Agent
Affected ❑ CW WW PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
❑ PWS:
ORW: yes /(1�6) PNA yes
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SubdivisioRl,
City /j tir•n ZIP
Phone # River Basin O
Adj. Wtr. Body :25;?7` SQ4-lknmd a /man /unkn)
Closest Maj. Wtr. Body
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Agent or Ap i nted N e
Signature Please read c pliance statement on back of permit
7eg M4 /(-2-4 6?3
Application Fee(s) Check #
ZV r,-----
rm Officer's Printed Name
S' ature
9, z'? - �9 /L •
Issuing Date
Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number:
Email Address:
I certify that I have authorized
S 17 '11 g rn a i 1. c, oti✓l
Agent /
to act on my behalf, for the purpose of applying for and obtaining all CAM4 permits
necessary for the following proposed development: jL�6&
at my property located at 'ec� _ t� Co�� r A�ctrv.aS�!�cl, , L
in 0County.
1 furthermore certify that I 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:
Sigfiaturej
Pnnj or Type Name
Y�l ��►-� r� 1\
Title
9,1—-1—�-F--
Date
This certification is valid through / /

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or re t #, Street or Road, City & County)
Agent's Name #: Mailing Address:
Agent's phone #:
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.
V 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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature—AVU
ilf
Print or Typ Name
1,:Za1 A,,
Mailing Address
u�ID4Ir,nron I �4ypc�
City/State/Zip
c tc (A7
Telephone Number
1, ci
Date
(Adjacent Property Owner Information)
Siignna ure (l
Print or Type Name
Mailing Address
City/State/Zip
Telephone Number
Date
Revised 611812012

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to s
(Name of Property Owner)
property located at { 6, M PS.te . c-JL, aL(3
(Address, Lot, Block, Road, tc.)
on i t in N.C.
(Waterbody) (City/Town and/or unty)
The applicant has described to me, as shown below, the development proposed at the above location.
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)
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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
C
Si �ture
h�
Print or Type ame
Mailing Ac1dress �T
City/StatelZip
-ki 191b--(,17-HDLO
Telephone Number
AU'6 _ CA ;)-Ul q
Date
(Adjacent Property OwneHnformation)
or TVA ame
r-J
Mail nl
�ng Address
,-o�� . d S39
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Telepho a urnbe
/S �DL
Date
(Revised 611812012)

Date Received
Date Deposited
Check From(NAM)
Name of Permit Holder
✓ardor
Check Number
Check
amount
Permit Number/Comments
Racei t or Reiund(Reallocated
Columnl
Column2
Column
Column)
Columns
Column0
Column?
Columno
Colu-9
8/29/2019
8/29/2019
Bur Smith Money Order
Sherry and Phil Jacobs
BancFirst
Coastal Bank and Trust
$ 200.00
GP #74614D JD rct 8532
GP #74615D JD rct 8533
-le
Li hthouse Marine Construction Inc.
Donald House
2839
600.00
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