67991D - Clark

�CAMA / ❑ DREDGE & FILL
GENERAL
L Iew ❑Modification
PERMIT
El Complete Reissue ❑Partial Reissue
As authorized by the State of North Carolina, Department of Environmen
and the Coastal Resources Commission in an area of environmental conc
Applicant Name
Address ��,e,�n tV �� f
City k-CI Statet� C zip (0 1 S
Phone # (�) Z� E-Mail ,
Authorized Agent �L� -C �'�-yC—' �V1
Affected ElCW AEW PTA El ES ElPTS
AEC(s): ❑ OEA ❑ HHF IH ElUBA El N/A
ElPWS:
Agent or pCp�licaat Printed Name
Signature Please read compliance statement on back of permit"
Application Fee(s) Check #
t and Natural
ern pursuant t
Previous permit #
C DO
o
Date previous permit issued
Resources
15A NCAC iJ7 rT � [ •7 [ J .X�0 /�� ��' �,� oO
❑ Rules attached.
Project Location: County ► V (&w -
Street Address/ State Road/ Lot #(s)
Subdivision Sr N SCCL
SV'VtQ ICI zip 26q(fZ
Phone # (`�ti 0) 3 G-7' EB.s River Basin
Adj. Wtr. Body_ w ( a /man /unkn)
SrG1v Fa�K ( I
PermitOffic is P ' d N
Al
Signature
I J64 170-7 6 Cl
Issuing Oate I Ex6iratiorwbate

NC ;Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: 3t 4 00'v — Permit #: `7 q
Date: 0 Vo �Vz cr[ %
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Name
TOTAL Sq. Ft.
(Applied for.
DISTURB TYPE Disturbance total
Choose One includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet .I
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
Ova
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑ Fill ❑ Both ❑ Other ❑
rl
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge. ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑. Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both p Other ❑
Dredge ❑ Fill 0 Both 1771 Other ❑

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson Dee Freeman
Governor Director Secretary
AGENT AUTHORIZATION FORM
Date: Jeff Clark
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project
Owner's Mailing Address:
908 Bennington Drive
Raleigh NC 27615
Agent's Mailing Address:
3235 Seacrest Ave SW
Supply NC 28462
Phone Number f 919) 349-7227 Phone Number 910 367-0335
1 certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
General Maint. on existing docking facility
(my property located) at 653 Augustine Ave SW Supply, NC 28462
This certification is valid thru (date) 1 /17
�Oak-
Rropet' Signature p
127 Cardriai Drive Ext, WArNNm, NC 29405
q%,AS-3964 Internet wwwnccoastalmanagement.net o� hca ohna
9

CERTIFIED TMAIL—RETURN RECEIPT REQUESTED
DIVISION OF COASTAL, lLkNAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to Jeff Clark is
(Name of Property Owner)
property located at 653 Auguatine Ave SW
(Lot, Block, Road, etc.)
on AIWW Brunswick
in
(Waterbody)
Applicant's phone #: [phone]
He/She hi
and I have .
omplete items 1, 2, and 3.
rint your name and address on the reverse
.:) that we can return the card to you.
- 'ttach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
Mr. itMl� �r l
�Su l i-4aw�i h oY . Laxu_
aoly-l09-e.-, nt C, a�sao+
(Town and/or County)
Mailing Address:
908 Bennington Dr Raleigh NC 27615
N.C.
rz
a
II I �IIIII II II �I I II I III i I IIIII I I II III II II III 3. Service Type ❑ Priority Mail Express®
❑ Adult Signature ❑Registered Mai1T"'
❑ Adult Signature Restricted Delivery ❑ Registered Mail Restricted
❑ Certified Mail® Delivery
9590 9402 2021 6123 2934 54 ❑ Certified Mail Restricted Delivery ❑ Return Receipt for
If you hav ❑ Collect on Delivery Merchandise } in writing
within 1.0 -- `r'^'for fmm service label) ❑ Collect on Delivery Restricted Delivery Signature Confirmation
7 016 0 910 p p 0 2 n Insured Mail ❑ Signature Confirmation D-ton, NC
D CM rep 12 2 2 8023 1 a I Restricted Delivery Restricted Delivery
Ps Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Return Receipt ;
(Property Owner Information)
lei/ .Qd� Authorized Agent
Signature
Will Richardson
Print or Type Name
3235 Seacrest Ave Sw
Mailing Address
Supply NC 28462
City / State / Zip
CRiparian Property Owner formation)
Signature '
Print or Type Name
Mailing Address
�'A Le/ /✓t� 27(d9
City / State4jip
Telephone Number 910-367-0883 Telephone Number 919- 7R'2 , �/032
Date 12-6-16
Phone:
Date Z
127 Cardinal Drive Ext., Wilmington, North Caro na 2 405-3845
910-796-72151 FAX: [phone] Intemet: wmAi.nccoastalmanagement.net
An Equal Opportunity 1 Affirmative Action Employer - 50% Recycled 110% Post Consumer Paper

Adjacent Property East:
Holden Family Ventures LLG
Cecil Holden
q 10-642-6516
Existing Boat Lift
ax16 float (�P
g2ft
bxb Covered Area
105FT Total distance
Scope of work:
Owner. Piling replacement-
Jeff Clark General maint. on decking
653 Augustine Ave SI^! No modifications to existing docking facility
Supply NC 2W2
q 14-34q-1227
!1OFT
COS
6FT NT5
Adjacent property owners west:
Timothy Brady/ Robert Brady
501 Hawthorne Ln
Charlotte NC 26204 ILIL
q 10-?55--112q
AINN
"loft Total distdance