74611D - Surf

�CAMA / DREDGE & FILL NO. 74611 A B C D
GENERAL PERMIT Previous permit#
ANew _Modification iComplete Reissue El Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environmental Quality i
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC /
❑ Rules attached.
Applicant Name / 1' wA.) 0 f 5 Project Location: County C N
Address 2 6 ( Cc kV iu L A) / � C N T /2 f ti � � � O f T "_'Street Add ress/ State Road/ Lot #(s)
City l v Q. F C t T y State NC ZIP7 N n ✓A1'�
Phone # f�LN Z 6 31 E-Mail Subdivision
Authorized Agent /U C A- City ZIP Z
Affected ❑ CW AEW 4 PTA t ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes /(11—oj PNA yes / no
Phone # ( �� River BasiriA-4t,'F a5L_k'
Adj. Wtr. Body W W (nat `mar /�unkn)
Closest Maj. Wtr. Body '5�T "144 %?
M.
in length
number
avg distance
max distance offshore_
cubic ds
ram
_1U1V'kF!HMMMM1I/7'7q7/`1*VA ARM
chBu
-
ell
reline Length
not sure yes
-tos: yes
W t& -1 up-rl-s
AWA orApplicaAt Printed Name
Inature* Please r d compli ce statement on back of permit*
4an o791�3
Application Fee(s) Check #
Pe icer's Printed Name
Signa e
Issuing Date
Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: ! owV1. .0 V-f
Mailing Address: 201 C o ✓AVVtuni j V ce v",i' ey- V
,5 v r-4' r +:�, . N C 28'`i K 5
Phone Number: A 0 - 328 - H $5 -7
Email Address: eVt%eYr�+� -Fo who sov�'ct �) .c0v-"
v
I certify that I have authorized
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: ar, n r i'ra - Irafl
loam! 0 -P Sou ,n dls %'o1 e tea r
at my property located at 51-7 Ro i" Hve , 5o r f Cl f U , KIC zo8 Hy5
in PCnOAeV
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:
A �K� _k�
Si natur
A5 H(en/ Loff iS
Print or Type Name
To w � Wi
Titl
(Q / 2 8 l11
Date
This certification is valid through

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: NCDOT
Mailing Address: 295E Jacksonville Hwy
Jacksonville, NC 28450
Phone Number: [phone]
Email Address:
[e-mail]
I certify that I have authorized Town of Surf City
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed developrnen(: placing rip -rap along
bank of Sound Side Park
at my property located at 517 Roland Ave, Surf City, NC 28445
in Pender
County.
I furthermore certify that I am authorized to g!-ant, and do in fact grant permission to
Division of Coastal Management staff, the Local hermit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
EDocuSigned by:
A4434EAD4F49476
Signature
Trevor Carroll, P.E.
Print or Type Name
Resident Engineer
Title
2 / 27 / 2019
Date
This certification is valid through 2 1 27 / 2022

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: 1 o w" Of 5U r -f C ,,i y
Address of Property: ,51 —7 t 0o low"c, (Ave t Surf C,*4 Y ,'NC -
(Lot or Street #, Street or Road, City & County)
Agent's Name #: A 51nf e i L.ofi-��S Mailing Address: -2o t C6M1 A\)V1,i V Cew{+G V
Agent'sphone#: Surf C41 NC 2&yy,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.
I havc 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, 28405-3645. 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
Print or Type Name
Zo t COPKVAUv.;+.f CQw v 1
Mailing Address
suer-(— C. 4 y , Ai C
City/State/Zip
glo -323 -4t 3 1
Telephone Number
(o�28�tq
Date — -- --
(Adjacent Property Owner Information)
r
Sig ur
Print or Type Name
%S 3
Mailing Address
City/State/Zip
Telephone Number
'71111
Date
Revised 611812012

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to I ow" o 4 5urf ��t y s
(Name of Property Owner)
property located at 5l -7 1Z o 6,v%d. Ave � 5u v-f C %*+,./ , t4c
(Address, Lot, Block, Road, etc.)
on 1npSa+! Soyvtid in S�vf C�fYItJC N.C.
(Waterbody) ' (City/Town and/or County)
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)
Si Miture
Q-stey Lod}is
Print or Type Name
2014 Covuww r%4�j CevJ2v- Dv,
Mailing Address
SLPY-F C1:4 , Nc. 2 gy4s
City/State/Zip
10-_3Z8'-413)
Telep one umber
— �.�'Cr-
Date
(Adjacent Property Owner Information)
Sim t
Print or Type Name
Mailing Address
W,111, ✓1c.tr
C°ty/State/Zip
f`h-)467-2f;' o
Tele Number
77
Date
(Revised 611812012)

TOWN OF SURF CITY GENERAL FUND P.O. BOX 2475 SURF CITY, NC 28445
079183
Vendor: NCDEQ015 NCDEQ
P0: 19-05257 DESC: Permit for rip -rap at SS Park 400.00
Check Date: 06/28/19 Check Amount: $********400.00

Date Received
Date Deposited Check Fm Name
Name of Petmlt Holder Vendor
Check Numbw
Chmk
amount
Permit Number/Comments
Rocel t w Refund/Reallocated
Columnl
Column2
Column3
Column4
Columns
Column!
column?
Column8
Column➢
7/3/2019 7/3/2019
ITown of Surf City
Town of Surf City
First Citizens Bank
79183
$ 400.00
GP #74611
JD rct. 8527