69322D - Butler

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' CAMA / -_ DREDGE & FILL S CA"'C I � l
w: GENERAL PERMIT �^'` 1V LS Previous permit# A B C D
New -.Modification '—'Complete Reissue CPartial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources yy // /�
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC OTT' • 2 SOO / 2-00
❑ Rul s attached.
Applicant Name ��'� Qvt & -1-,r-< Project Location: County
Address i �ef �i S ST Street Address/ State Road/ Lot #(s)
City -40 (At6� StateAX ZIP
Phone # ( ) E-Mail
Authorized Agent LAOt # h
Affected ❑ CW *W ❑ PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
ORW: yes /(no) PNA yes f no
Type of Project/ Activity
Pier (dock) length
Fixed Platform(s)
Floating Platform(s) �►G
Finger pier(s)
Groin length
number
Bulkhead/ Riprap length
avg distance offshore
max distance offshore
Basin, channel
cubic yards_
Boat ramp
Boathouse/ Boatlift
Beach
Other
r
Shoreline Length 5n
SAV: not sure yes no
Subdivision
City
ZIP r
Phone # ( ) River Basin F IZ
Adj. Wtr. Body Cay.A(S (natnat /j;Z�nkn)
Closest Maj. Wtr. Body P-=- w (,J
Moratorium: n/a yes (no
Photos: yes 'no
Waiver Attached: yes o
A building permit may be required by: _� ptj.
( Note Local Planning jurisdiction) —��/ x,�,�
Notes/ Special Conditions � ^�'t.2ZO /17,0 0
Ag,ent or>App nt Printed N e t
Signature "Please read compliance statement on ack of permit'**
(Scale: tJ T5' )
❑ See note on back regarding River Basin rules.
oca. �
Sighature - `'" "'
nlhAll;z oblri-
Issuing EJ;;t;r Exp4atioj Date
Applicatibn Fee(s) . N r . - Check #

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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.
. Article Addressed toJ•
��
r11IL'^— W,6U", �Iq
III'lll�l IIII I�iIiiIIII IIIIIIIIIII II�IIIIi I III
9590 9402 1661 6053 1773 86
A,*i-JA Number (Transfer from service label)
7015 1520 0003
PS Form 3811, July 2015 P '-'- 7094
I
A. Signature—�
X
B. Received by (Printed Name)
C. Date of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES. enter delivery address below: Cl No
o. service type
❑ Adult Signature
❑ Priority Mail Express®
0 Adult Signature Restricted Delivery
❑ Registered Mail-
❑ Registered Mail Restricted
❑ Certified Mail®
Delivery
❑ Certified Mail Restricted Delivery
❑ Collect on Delivery
❑ Retum Receipt for
(�
❑ Collect on Delivery Restricted Delivery ❑ Signature Confirmation.
❑ Insured Mail
❑ Signature Conflrmador
❑ Insured Mall Restricted Delivery
- e;om
Restricted Delivery
Domestic Return Receipt
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CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property.
/,2-7
(lot or Street S. street
Agent's Name #. L1aIu-1 d4las q
Agent's phone *: llQ� yq H— �,c�I V
P'rcoao, uty d County)
Mailing Address 20,
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 drawino, with dimensions, must be provided with this tatter.
1 have no objections to this proposal. - - - 1 have objections to this proposal.
t1you have objections to what is being proposed, you must noddy the Division of Coastal Afarwgement (DCN) in
wrhfng wfthin 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardirnal Ddve Ext,
Wlxmblgton, NC, 28405-3W, DCAI rapresentndv*s can also be contacted at [phone]. No response is
conslderyd the same as no objecdon f1 you have bean rmWed by CarWW A1all.
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) � ®,� /'S +d
Nr .l 1 do wish to waive the 15' setback requirement. ple/- 1/ 4el-q
10N?J-oe-k
I do not wish to waive the 15' setback requirement.
(Propery Own o�pMti )
Signature
Print or Type Name
(Adjacent Property Ow Infonnation)
X
Signature
Pnnt or Type ame
Z &:2 4-5dJ
Usling Address
iry t '
74
Telephone Number
w,whg Address
6 Z4 C
City WZip
Teh")hone ivvmoer
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Dufe

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North Carolina Department of E-^vlronment and Natural Resources
N.0 Divis+or of Coastal Management
John E. Stvaft, III
Smewry
AGENT AUTHORIZATION FORM
Date 3/- J 7
Name of Property Ow er Applying for Permit Narne of Authorized Agent for this project -
Owner's Mailing Address
Agent's Matting Address.
Emad Emad Ane kS AS E t- -A -co-n
Phc Ie 11/d Phone Lqp_J_�(� -
1 �ert!{y that I have authorized the agent !;sted above to act on my behalf, for the purpose of applying
for and obtaining all CA MA ermits neces ary to install or construct the following (activity)
i 1 _ / . n l /1
For my property located at
ThiS certification is valid 1 year from (date) ��3/— / 7
Property Owner Signature Date
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