69194D - Caudle

aACAMA / 'REDGE & FILL ?�
ffNERAL PERMIT A'�t.
ew _ Modification ❑Complete Reissue []Partial Reissue
As authorized by the State of North Carolina, Department of Environment and Natural
and the Coastal Resources Commission in an area of environmental concern pursuant t
Applicant Name Dcl y' G� h. Ann ((w d u
Address U120 �ALj[,e �GltUe
City ?? State AX ZIP
Phone # (TO (A b 2 ,J �'E-Mail ,
Authorized Agent /A U r F �( 6 U Vlt ll
Affected ❑ CW gEW *A fXES 9TS
AEC(s): ElOEA ElHHF ElIH ElUBA ElN/A
El PWS: _
A`geq or Appl!�an"t Printed Na ye
Signature Please read compliance statement on back of permit
(4a-) lfL-11 g-
Application Fee(s) Check #
Previous permit #
Date previous permit issued
0
Resources-�f
15A NCAC Cl+i . 12CO (}Z,
Rules attached.
Project Location: County J V-V ( tut c y4 r
Street Address/ State Road/ Lot #(s)
Subdivision
K ity N! 1 n1 i ►�U�CN ZIP U� 1
"VP one # (q1L)) to? 1 0 9 River Basin caG --
Adj. Wtr. Body A � W (nat /wan unkn)
C DD
A`geq or Appl!�an"t Printed Na ye
Signature Please read compliance statement on back of permit
(4a-) lfL-11 g-
Application Fee(s) Check #
Previous permit #
Date previous permit issued
0
Resources-�f
15A NCAC Cl+i . 12CO (}Z,
Rules attached.
Project Location: County J V-V ( tut c y4 r
Street Address/ State Road/ Lot #(s)
Subdivision
K ity N! 1 n1 i ►�U�CN ZIP U� 1
"VP one # (q1L)) to? 1 0 9 River Basin caG --
Adj. Wtr. Body A � W (nat /wan unkn)
C DD

Date
Date
Check From
Name of Permit
Vendor
Check
Check
Permit Number/
Receipt #
Received
Deposited
Name
Holder
Number
amount
Comments
5/19/2017
Clements Marine
David and Ann
First
4415
$600.00
GP 69194D
CS rct. 3392D
Construction
Caudle
Citizens
Bank

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: p.'"' L
� I # �oq /,?q
Date: 91m I �
Describe below the HABITAT disturbances for the application.
All values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FINAL Feet
(Applied for.
(Anticipated final
(Applied for.
(Anticipated final
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disturbance.
Habitat Name
Choose One
includes any
Excludes any
total includes
Excludes any
anticipated
restoration
any anticipated
restoration and/or
restoration or
and/or temp
restoration or
temp impact
temp impacts)
im act amount
temp impacts)
amount)
Dredge ❑ Fill Both ❑ Other ❑
2
HG
Dredge ❑ Fill ❑ Both ❑ Other
Z t/ V©
IN
Dredge ❑ Fill ❑ Both ❑ Other
(4� ('-41 O
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

Letter of agent
I DAV iQ No, -A k have retained Mark Clements DBA, Clements
Marine Construction Inc, to make application for any and all permits needed to start
construction on the work requested for our property or properties.
By allowing Mr. Clements to make such applications I do understand that this will in no
way relieve me of any obligations to perform all work according to the building codes of
North Carolina, CAMA, DWQ or any other state and or county ordinances.
ix-
Print
Signature
17!0- '�'b'C' 23C)2
Contact information
date 5"
RECEIVED
DCM WILMINGTON, NC
MAY 10 2017

■ Complete items 1, 2, and 3. A g tare
■ Print your name and address on the reverse Agent
so that we can return the card to you. dressee
■ Attach this card to the back of the mailpiece, Received by rint ame C. Date of Delivery
or on the front if space permits. orudfiLl) "-
1. Article Addressed to: D. Is delive ddress ddtwent#rom❑ Yes
POY10-6 If YES, delivery address' beloul tp�p No
MAY f j 2017
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❑ AdultSignature O 9� ecl Mai TM
❑ Adult Signature RestrlcteQBeltvery _ �� 6gistered Mail Restricted
9590 9402 2377 6249 9967 16
Certified Mail@ Delivery
❑ Certified Mail Restricted Delivery ❑ Return Receipt for
❑ Collect on Delivery Merchandise
2. Article Number (Transfer from Service label)
❑ Collect on Delivery Restricted Delivery ❑ Signature ConfirmationTM
7 016 2 710 0001 013 7 716 6
El Insured Mall Delivery ❑ Signature ConfDelivery
l Insured Mail Restricted Restricted Delive
(over $500)
PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Return Receipt
■ 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 to: 11^�
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A. Signature
❑ Agent
J11 Addressee
B. Receiv d byfrinted N me) C. Date of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
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III
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3. Service Type
❑ Priority Mail Express@
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❑ Adult Signature
El Registered MajlTM
❑ Adult Signature Restricted Delivery
❑ Registered Mail Restricted
9590 9402 2377 6249 9967 23
xCertified Mail@
Delivery
❑ Certified Mail Restricted Delivery
❑ Return Receipt for
❑ Collect on Delivery
Merchandise
2. Article Number (Transfer from service label)
❑ Collect on Delivery Restricted Delivery
❑ Signature Confirmation-
11 Insured Mail
❑ Signature Confirmation
7016 2710 0001 0137 7173
] Insured Mail Restricted Delivery
Restricted Delivery
(over $500)
'S Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: bAY 112 a ;A IC -
Address of Property:
yl/
(Lot or Street #, Street or Road, City & County)
Agent's Name #: 6z< (2,)e 1'f5 Mailing Address:
i 1 Z C,rc 1e Or-r, vac. to �5iec_� (k- Z`5443
Agent's phone #: ) I P d Zr
Nvte� i h►5 �orNt ,,�,,�C ll-e GIS�d h2 > J')ea�G'1,i Rer �Pr�YIi �,
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 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. Contact information for DCM
offices is available at www.nccoastaimanagement.net/contact dcm.htm or by calling 1-888-
4RCOAST. 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.
y I do not wish to waive the 15' setback requirement.
(Property Owner Inform tion)
Signature /
/%ran f VAMP,
(Adjacent Property Owner Information)
Signature
�rrrl R�►�Mtl RECEIVED
DCM WILMINGTON, NC
MAY 10 2017

Print or Type Name
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Mailing Address
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City/State/Zip
,5110 6�c9,.5o5
Telephone Number
Jr-T._/ 19
Date
Print or Type Name
Mailing Address
City/State/Zip
Telephone Number
Date
Revised 611812012
RECEIVED
DCM WILMINGTON, NC
MAY I 0 2017

Postal
CERTIFIEDo RECEIPT
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❑ Return Receipt (hardcopY)
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Return Receipt (electronic) $ SI rlfr
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❑ Certified Mall Restrcted Delivery $ V Y
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Total Postage and Fees
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CERTIFIED MAIL' RECEIPT
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NORITH AUGUSTA ► S0 24860
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Certified Mail Fee 7tt J.J�1 -
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$
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Extra Services & Fees (check box, add tee _ ate)
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❑ Return Receipt (hardoopY) $
Return Receipt (electronic) $�J 11
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Postage
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DCM WILM NI G ON, NC
MAY 10 2017

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RECEIVED
DCM WILMINGTON, NC
MAY 0 2017