74255D Poole

XCAMA / ❑ DREDGE & FILL NO. 74255 A B C
GENERAL PERMIT Previous permit #
IXNew ❑Modification [-]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
❑ Rules attached.
Applicant Name Rot3ERT iI��LF Project Location: County 9RtiA45V1C_K
Address j a 42- CXI M SoN OAK CT Street Address/ State Road/ Lot #(s) � 1-
City HARRi-Tod S Stated ZIP Zr075 T)A1FE_ 57-myr-r
Phone # (104) 05, - 3811 E-Mail _AI A Subdivision AJ A
Authorized Agent 9-A C 'I rAIR JA ER City OCSAN __rSkAr- QEAtN ZIP 284L9
Affected ❑ CW )(EW gPTA ❑ ES ❑ PTS Phone # (510) 44 3 - 7 7 9 3 River Basin Lu m er-it-
❑ OEA ElHHF ❑ IH El USA ❑ WA
AEC(s): Adj. Wtr. Body CM1/A V (nat
❑ PWS:
AA_: %A/a.. D—A.. A I W W
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Agent or 4p itapt Pri ed Name
Signature ** Please lead compliance statement on back of permit **
1; 2 00 4 IN g
Application Fee(s) Check #
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Permit Officer's Printed Name
Signature
/17 /i 9 1
Issuing Date Expiration Date

CCEDEMR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
'at McCrory Braxton C. Davis John E. Skvarla, III
Governor Director Secretary
AGENT AUTHORIZATION FORM
Date: IT
a roperty ner Applying for Permit: Name of Authorized Agent for this project:
d AL 1 �
nmer's Mailing Mdr,ess, O
tone Number ( °� Ja-5 3,S i I
Agent's MaNny Address:
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Phone Number( �/v K3 - —/"7 � 3
ertify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Per its necessary to inst II or construct t,4 foilowin (a 'vity):
is 14A/ 5(' -C Fl, L>} t ►ter - (M C ')7:;, �`1-f l �s��.� � i � ►�� 'S�_
r my property located at . 7/
s certification is vaH th ate)
Property Ow�er Signature
:S�-19
Date
127 Cardinal Drive Ext., Wilmington, NC 28405
Phone: [phone] FAX: [phone] Internet: www.nccoastalmanagement.net
NocorthCarolina
NaAMAY
An Equal Opportunity 1 Allirmative Action Employer

US MAIL
CERTIFIED MAIL - RETURtN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACEN'� RIPARIAN PRO)!XrY OWNER STATEMENT
Name of Property Owner: Lb rA'>/ C) I -
Address of Property:
(L.ot or Street k, Street or Road, City & County)N
Applicant's phone rr �� V f—o�-)�/ Mailing Address:
I hereby certify that 1 own property adjacent to the above referenced property. The individual applying for this permit
has described to me as shown on the attnehed drawing the development they are proposing. A description of drawi
ng
with imensiQns must prov'ded wit tjiis letter.
CC- I have no objections to this proposal. I have objections to this proposal.
If you have objections to what is being proposed, you tnust 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. DC1VI 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, or lift must be set back a minimum distance of
15' from my area of riparian access unless waived by mc. (If you wish to waive the setback, you must initial the
7-7
opriate blank below.)
C� _ I do wish to waive the 15' set back requirement.
I do,4ot 3Rish to waive the 15' set back requirement.
nation) (Riparia roperty 0%Yn nformation)
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Mail' g Address
City/ State / Zip
Telephone Number
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Print or Type Name
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Mailing Address
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City / State / Zip
Telephone Number SOLIS2—
Date s— 7 — /
127 Cardinal Drive Ext., Wilmington, North Carolina 28405.3845
Phone: [phone] l FAX: [phone] Internet: www riccoastalmanagement.net
An Equal Opportunity 1 Affirmative Autm Employer - 50% Recyded t t tr/o Post Consumer Paper

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1. Article Addressed to:
C41YIS N0oISN
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9590 9402 4036 8079 7369 06
)018 0680 0000 7024 7587
PS Form 3811, July 2015 PSN 7530-02-000-9053
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❑ Addressee
C. Date of Delivery
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D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
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Merchandise
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Restricted Delivery
(over$5()0)
Domestic Return Receipt

US MAIL
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CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner: _
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Address of Property:
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(Lot or Street #, Street or Road, City & County) o p,
Applicant's phone #: ?O — q)_ 3'W t t Mailing Address: 5__�69_D— ram+ 5�y Gr
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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.
�7
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, 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.
(Property Owner Information)
Signature
Print or Type Name
Mailing Address
a, T�
City / State / Zip
Telephone Number "Z _ %�� 3O/�
(Riparian Property Owner Information)
Signature
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Print or Type Name 1�14
Mailing Address
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City / StateM p�
Telephone Number
Date Date Z,�
127 Cardinal Drive Ext., Wilmington, North Carolina 28405-3845
Phone: [phone] FAX: [phone] Internet: www.nccoastalmanagement.net
An Equal Opportunity 1 Affirmative Action Employer - 50% Recycled 110% Post Consumer Paper

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■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
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I IIIIIII I'll liIIII ll Il IIII III III IIIII Il III
9590 9402 4036 8079 7368 90
A. Signature
❑ Agent
Mj ❑ Addressee
Received by (Print N e) C. Date of Delivery
4 - I q - lI-
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Service Type ❑ Priority Mail Express®
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❑ Collect on Delivery Merchandise
2. Article Numtter (Transfer from sarvirwho0 ra❑Collect on Delivery Restricted Delivery ❑ Signature ConfirmationTM
] Insured Mail ❑ Signature Confirmation
7 015 0920 0000 7 610 4257 7 Insured Mail Restricted Delivery Restricted Delivery
(over$500)
PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Return Receipt

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Date Received
Dafe aged
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Name of Permit Holder
Vendor
Check Number
Check
amount
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