74602D - Schiefelbein

CAMA / ❑DREDGE & FILL NO. 74602 A B C i�
C;ENERAL PERMIT Previous permit #
New ❑Mocation El 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
❑ % r Rules attached.
Applicant Name * �% �G� 7 E Ul- Project Location: County
Address— (Q �sa"�l. Street Address/ State Road/ Lot #(s)
City f State ZIP7�-yI(r / � / /�'%rl� 5&1A 0yy�� i
Phone # ) -: T/ ` `E-Mail
Authorized Agent u 14—
-J,
Affected ❑ Cw VW '�)IeTA ❑ ES ❑ PTS
AEC(s): ❑ OEA /❑ HHF ❑ 1H ❑ UBA ❑ N/A
❑ PWS:
ORW: yes - no` PNA yes / no
Subdivision
City L �% ZIP
Phone # River Basin1w (ACU na f•�
Adj. Wtr. Body L"R' an unkn
Closest Maj. Wtr. Body
Type of Project/ Activity j (P � 6' 5 1 t (' 'T�>Ow 1J
Pier (dock) length /
Fixed Platform(s)
Floating Platform(s)
Finger pier )
Groin lens
Bulkhead/ Riprap li
avg distance <
max distance
Basin, channel
cubic yards
Boat ramp
Boathouse/ Bodtl
Beach
Other
Shoreline Length b
SAV: not sure yes
Moratorium: n/a yes
Photos: yes
Waiver Attached: es
A building permit may be required by:
( Note Local Planning jurisdiction) ,
Notes/ Special Conditions
or ADDRcant Pri
S(gnature Pjgasifread compliance statement on back of permit
(Scale:
❑ See note on back regarding River Basin rules.
=5:'' �tle)T A v
PerfrIitO"er'sted Name
Sign re
�-� /
Fee(s) Check #
Issuing Date
Expiration Date

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property YOwner Requesting Permit: g�,-r Jep
Mailing Address: 1(Q / K � '�j soy� 1�w
Phone Number: �l9 3 33 — qu 6 -�-
Email Address: t"u������� 2 Z� (- _ ci
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:
at my property located at
in County.
I 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:
l Signature
� wl J —
Print or Type Name
Title
�l,,2)--1 2--
aD to
This certification is valid through 4 1 ZZ!

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to _ /ii %C/� f�//<l Is
(Name of Property Owner)
property located at jI R�711VS�N
(Address, Lot, Bloc Roa , et ) .
on , in
N.C.
(Waterbod
y) (City/Town and/a County)
The applicant has described to me, as shown below, the development proposed at the above location.
_-- X 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)
.Y-/—
s TD 6&-V�'s
WAIVER SECTION #Utt•
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) (Adjacent P operty Owner Information)
— 1-0� 11�
Sign f e_ e a y)Z�- � Signal J
Print or Type Name Print or TNa
I (1( ,A 7i t,,t J Ste' �� ye �
Ma W g ess Mailin Addr
u (24� ti� � M UI � IA4
citylta e/Zi City/State/Zip
-7 7a0
Telephone 671 mber Telephone Number
Date —�
Date
(Revised 611812012)

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property: _ _ r � / � / 14,.6�) KJ�,
(Lot or Street #, Street or Road, City & County)
Agent's Name #:
Agent's phone #:
Mailing Address:
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 areproposing. A description or 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 (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 q 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.)
C14-1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Pro
perty Owner Inform p}-
, !C> L 7
Sig
n
ature
Print or Type Name
i "/Az)
Mailing Address
11rCliy,/vc-.��
City/StaterZip
�mi
Telephone Number
/,l /ao/i1
Date
(Adjacent Property Owner Information)
Signalure
Pnnt or Type Name
Mailing Address
City/State/Zip �-
336--
Telephone Number
Date
ly --Z�o ( 5
Revised 611812012

Yj
IN
i
C4Nk & � ( WA::

Date Received
Date Deposited Check From Name
Name of Ps —it Holder
Vendor Check Number
Check
unt
Permit
Receipt or Refund/Reallocated
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