68507D - Crouch

CAMA / DREDGE & FILL�j850i
GENERAL PERMIT Previous permit# A B c
'New Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources ����//��
and the Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC- Q K, �Z 00
❑ Rules attached
Applicant Name A CK-04 ct". Project Location: County Z00 15 w .
Address
City •i-(a ({-_ m 60t�, State_ ZIP 7 Sq ( Z
Phone # (q 1 ) SY4 - 39 51 E-Mail
Authorized Agentg�,t„���„r 1�0.�•�nC �wnC-f
Affected ❑ CW )(EW ❑ PTA ❑ ES ❑ PTS
AEC(s): ❑ OEA ❑ HHF ❑ IH ❑ URA ❑ N/A
❑ PWS:
ORW: yes /6) PNA yes / no
Type of Project/ Activity 4Z (a JU riam
Pier (dock) length
Fixed Platform(s)
t
Floating Platform(s) X 2-0
Finger pier(s)
Groin length
number
Bulkhead/ Riprap le��t
avg distance o
max distance
Basin, channel
cubic yards
Boat ramp
Boathouse/ Boatlift
Beach Bulldozing Nr
Other 1ial '( P 3' X If
DW 110 D
It
Agent or Applicant Printed Name
Signature ** Please read compliance statement on back of permit*
2.00 --3 5
Application Fee(s) Check #
Street Address/ State Road/ Lot #(s)
Subdivision
City__ ZIP
Phone # ( ) River Basin L
Adj. Wtr. Body f �j�VLQ_ (nat(fman unkn)
Closest Maj. Wtr. Body AZ'.JtJ
77
(Scale: j" = 20 )
❑ See note on back regarding River Basin rules.
CbOL s S t,
[Officer's Printed Name
�u� Date
111311,6
&-pirfition Date

oa; McCrory
,kvernor
��
North Carolina Department of Environment and Natural Resources
N.0 Divisior of Coastal Management
.lout E. Sbarta, III
SWOWY
AGENT AUTHORIZATION FORM
Date
Name of Property Owner Applying for Permit Name of Authorized Agent for this project-
J n 5 N . C=iroo d----- - - _!A�A) e. Nlonre
Owner's Mailing Address -
all
u ,& V a . %
Email
Phone
Agents Malifiirlrg Address:
1g,62 K r' r 9d - ,
?KNb Z,
Email �pdS 2� i(C Ji Cn
Phone---
i cervfy that I have authorized the agent Itsted above to act on my behalf for the purpose of applying
for and obtarnng all CAMA Permits necessary to install or construct the following (activity).
For my property located at alelen
This certdicatton is valid 1 year from (date)
7
Property Owner Signature Date
'ti Caf" Dn* E,f . ftnrngw, NC 1t3 X
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CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:.1
Address of Property `� c - f
(Lot or Street 8. Street w moac, Cry 6 County)
Agent's Name #t: zIrvu. L-10 /111-
Agent's phone #: �lD� �/ 3— ` 2
MaibN Address &
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 deveiopmerst
they are proposing. A description or drawing with dimensions must be provided with this fitter.
` ,.��1 have no objections to this proposal. I have objections to this proposal.
t d you have objectioru to what is being proposed, you must notify the Dhisfon or Coastal Uan&gerrtent PxA1) in
wrttfng within 10 days of receipt of this notice. Correspondence should be marled to 127 Cardinal Drt►o bxt,
Mbnk gton, NC, 28405-3845. DCM representatfws can also be contacted at [phone]. No responsr is
consfdared the same es no objection d you he" bean notified by7Cerd ied Abil.
WAIVER SECT)ON
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 aive the setback, you must initial the appropriate blank below)
fgal its 1 do wash to waive the 15' setback requirement
IW-o
! do not wish to waive the 15' setback requirerrtent.
(Property Own 1a�rsati 10
6WIew —
((jj Signature
tie
Print or Type Name
1 ! —2 , 5�
Mating Address
Telephone Number
rmli
(Adj t Prorej n r formation)
Signature U
�C>L-�s �1�Z
Print or TypefName
/32-.
Marling Address
ad", A c 6 2-
city
li0-%42--` T' g
Telephone Number
t)are —

P�
1Z�e Toaeor\ 6� N,3
Flo��',��
IJocic
O,nd
i Orw\rJ
w4h New.
20

■ 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:
Lew Cs M `+c h e Q
13 Z I ctrPorN S v
Nold>°n R etic.h �vC, 2ky � Z
(II�II'IIIIIIIIIIIIIII IIIIIIIIIII IIIIIIIIIIII
9590 9402 1661 6053 1774 16
A. Signature
c
X Agent
rCDate
Addressee
B. Recepv by (Printed Name) of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
RECEIVED
DCM WILMING ON, NC
SEP 14 2017
3. 5ervice Type
❑ Adult Signature
li
0 Priority Mail Express®
dult Signature Restricted Delivery
❑ Registered Mail—
❑ Registered Mail Restricted
Certified Mail®
❑ Certified Mall Restricted Delivery
❑ Collect D
Delivery
0 Return Receipt for
on every Merchandise
2. Article Number (transfer from services 1ahP11 ❑ Collect on Delivery Restricted Delivery 0 Signature Confirmation*
7 016 0910 0 2 12 2 3 12 6 9 sured Mall 0 Signature Confirmation
sured Mail Restricted Delivery Restricted Delivery
er$500
PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Return Receipt