72711D - Surles

JACAMA / ❑ DREDGE & FILL
GENERAL PERMIT
XNew ❑ Modification ❑Complete Reissue ❑Partial Reissue
No. 72711 A B C
Previous permit #
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 0 (2 O
❑ Rules attached.
Applicant Name k IA C-11.1 p[ ` 1A 4AA1 `SA RL r r
Address —I;?-(* 1ff:>RAAJno„/ DP%vr_
City �—I LL I At TOW State ZIP 2 7 54 (0
Phone # (g19) 4 2 2 - 10 (., S E-Mail 4�,A
Authorized Agent 61 P I C t C-0 JST R N C T1 u A/
Affected ❑ CW �QEW PTA .*W11• -OM-
AEC(s): ❑ OEA HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes / no PNA yes / no
Project Location: County & Lk AI sW I C K
Street Address/ State Road/ Lot #(s) 5&
! AuRFn/C�uRA JTRCr—
Subdivision 14/,4
City UCKAiV _ -S,r_ BE ZIP 2-P46q
Phone # (i110) 579 - 9 Q9 5 River Basin L u IAfS ER
Adj. Wtr. Body C AA/A (nat &a�)/unkn)
Closest Maj. Wtr. Body A I W W
Type of Project/ Activityr
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Agent or Applicant PrinteO t4ame
Signature Please read compliance statement on back of permit
jt;zoo 127
Application Fee(s) Check #
' `IL I;K 1A C CAI,�IR�
Permit Officer's Printed Name
c
Signature
28 2019 5 28 2)Iq
Is iusls ng Date Exp lion ate

Air'.
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C Davis John E Skvarla, III
Govemor Director Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FUKM
Date: �
Name of Property Owner Applying for Permit
A 4
Owner's Mailing Address:
. r
Phone Number (`i I C) L(J-)
Name of Authorized Agent for this project
C-TrrSQ_G% �IJn
Agents Mailing Address:
Phone Number Lho ) s- 9 - cm
I certify that I have authorized the agent listed above to act on my behalf. for the purpose of applying
for and obtaining all CAMA PMQV--
s necessary to install or construct the foll wing (activity):
��Q a ru.m,-)/ Tns% l ( r� boq f /� 7
For my property located at
This certification is valid thru (date)
Property Owner Signature
Date
127 Cardinal Drive Ext., Wilmington. NC 28405
Phone [phone]', FAX: [phone] Internet: www.nccoastalmanagementnet
An Equai OwNnuty Aftminve Action Employer

N
'7
A4etlrs Warti t5t' 1CaQ. R5t('tUlaiUMA&-ess:tLtUY� : tG
I hereby cedify_tiiat I own property adjam tt.to the above refe"ced-.property. The individual aping for
, sfriti ha-opscribed to me as sham on the attached-. the development they atet propo. inn.
1 bpe no abja bons to this propma i have objeoiions to this propoW.
WA VElt'SECnON
l understand.ftta pier, dodo ,mooting pill gs. brook~ bo , toc.'roln :must be sei
mtnlmwrdis#snce of i 6' mY area' of ffip r t access l ivied b . f#;y3tt Wtst4 U. �+laive;
setbaEi<, ��.lrf I II S1C t118'BpprOpnate'��ankbelCflAf.)
n I :do with to waive the I5' setbaclr-req&emenC-'
I d ittR-waive.the I& setback regt"r 6rtt.
l(Propetrty. Owner info rmation} h (Aa) nt Proper ter rtAOr j
Simatwe : afore
Pint7jrpt3 fila a Printt or.7: Type da�rtr :
M��A�: _
2 5_q2. k-rlD d
zok* bAziD
Telephonai Number Teleph mber
Date 'Poe
Revised fi1M2012

CERTIFIED MAIL - RETUWRECEIPT REQU_ ESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPdATY OWNER NOTIFICATIONNYAIVER FORM
Fume of Property Owner:
ddress of Property: ZI 10 1 ` '
GC (Lot or Street #, Street or R , Ci & County)
Agents Name#.jCt �r6 up k�() Mailing Address:Jk'b &QC�A
Agents phone *%D— 57-gbg5 &ps_�X N.0 2-c6%G
t i hereby certify that I own property adjacent to the above referenced property. The individual apeiyi, ,, for
-- -- r1.s .it has described to me as shown on the attac. the development the, are pm�+'s ,
C"
15
S.1 1 have no objections to this proposal. I Have objections to this proposal.
.) W1—
If you have objections to what is being proposed, you must notify the Div' n of �ld
al
Management (OCM) in writing within 10 days of receipt of this notice. Con shay
mai�'ed to 127 Cardinal Drive Ext, Wilmington, NC, 28405-3845. DCM represe e
contactedat (910) 79&7215.-Ne-response is considered the some as no objectio been
"aged by Certified Mail — —- - --
WAIVER SECTION — --_
i understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or grain must be set back a _
minimum distance of 15' from my area of riparian access use -waived by me. (if you wish to waive tr.11a
setback, you Must initial the appropriate blank below.) -- - --
V 1 do wish to waive the 15' setback requirement _
I do no wlto waive the 15' setback requirement.
— - - (Property Owner Information) 'di lOAwner hif�orntation)
t
N��c �Rk�j Lcee
Sib ature Sig nature
Print o ype Name Print or Type Name
Flailing Address -- _— _�— Mailing Add/r_ess I
-7 5' 44 /k
CVStateMp City/Stateaip
Telephone Number Telephone Number
Date D e Revised 611 01

Dafe
Dab Roeefved
Deposited Check From (Name) _ _
_
Name of Permit Holder
Vendor
Check Number
Check amount
Permit Number/Comments
Recelpf or Refund/Reallocated
Cokm i
Column2 Column)
C.1-4
coin s
Column.
Column]
Column8
CoWmn9
1/27/2019 Grice Construction
I Hu h and Susan Surles BB&T
12729
$ 200.00
_
! GP #72711 D
TMc rct. 7727D