73537D - Jackson

IXCAMA /.XDREDGE & FILL No. 73537 A B C CD
GENERAL PERMIT Previous permit #
I<New El 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 0714, 1100
❑ Rules attached.
Applicant Name /�/��SJ� ❑hc -res it Project Location: County 71zv.t4Sty 1 e-ic
Address Yo 13 oX 97 Street Address/ State Road/ Lot #(s) 1 ( Z
CityI gK.TO^/ State ZIPZ8'3'71 .J i A>;2. F1sN l),V
Phone # (91) 3o3 — 2830 E-Mail _-J1A Subdivision V /A
Authorized Agent CAR t0ti _ A, City y",AMAJ UrAcN ZIP z84G2_
Affected ❑ CW ❑ EW ❑ PTA X1 ES 'KPTS Phone # ( 1o) ��¢U - 6 $i o River Basin Lu H9,rQ
AEC(s): ❑ OEA HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body CA.-JA L. (nat ma /unkn)
❑ PWS: h
ORW: yes /(o� PNA yes / Closest Maj. Wtr. Body W
Type of Project/ Activity R!L_PI.ALr=_ F-K IS-r cAsly �c,uJ��Eec I '-J
S AM I— ALA Ci N M F_ AI r (Scale: l 2 )
Pier (dock) length
Fixed Platforr
Floating Platfc
Finger pier(s)
Groin length
number
,4u
lkh ip
avg dista
max dist
Basin, channe
cubic ya.
Boat ramp _
Boathouse/ Bi
Beach Bulldoi
Other
Shoreline Len
SAV: n
Moratorium:
Photos:
Waiver Attact
A building permit may be required by: I —yEN /f See note on back regarding River Basin rules.
( Note Local Planning jurisdiction)
Notes/ Special Conditions O'7 N 1 (C) O Bc ALL 01i-1E R L OC,AI. , S1 A-i r- _ $
I^EpERAL iZFCncAL_,AT,o.j-, ,,ApvL_y.
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Agent ',Appl71tPritdd �d e
Signature ease re'ag compliance statement on back of permit"
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lication Fee( Check #
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PermitOffice_r'ss Printed Name
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Signature
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Issuing Date Expiration Date

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CERTIFIED MAIL — RETURN RECEIPT REQUESTED
DIVISION OF COASTAL NE42NAGEIVIENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner: %660 ^ C��C�SOln.
Address of Property:-i(+,t� C' r
(Lot or Street 9, Street or Road, City & County)
Applicant'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 of 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 (DCbi}
in writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Eat.
Wilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]_ No response is
considered the same as no oblec don if you have been notified by Certified Mail.
WAIVER SECTION'
I understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift 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' set back requirement_
I do not wish to waive the 15' set back requirement_
Owner
v
Print or Type Name
lYt sov\ ZAtiso L,
Mailing Address
City / State i Zip
Telephone dumber
Date
Property Owner
-D4,e,y-(- z —
Print or Type Name
I R, 0(6-14GV06-0s PR.IJC,
Mailing Address
N<- a-ITjo
City / State / Zip
Telephone Number c)) c) r 3 7 Y~-7Y 3
Date &- (-�-- /`)

-7 s-�n fs -ell

Dar. Received
Date De sited Check From Name
Name of P~ Holder
Vendor
Check Number
aChockmount
Permit NumberlComr—ts
Rece/ t or Refund/Reallocated
Columnl
Column
Column
COW."
Columns
Columns
Column?
Columns
Column9
1
oleen Oxks and Bulkhe
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P a7 7
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