66630D - Alderson

CAMA / ❑DREDGE & FILL l5� `6 1 'z
"GENERAL PERMIT Previous permit # A B
New ❑Modification El Complete Reissue ❑Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources l( o
Ooastal Resources Commission in an area of environmental concern pursuant to I SA NCAC �� 1� , t V
`` ❑Rules attached.
Name ��'�1 �V�tt� Gl !� �� >� �� o- h Project Location: County `2V\� S
Street Address/ State Road/ Lot #(s)
State zip L � � s � t % `,; .
E_Mail Subdivision
ad Agent ��. (Can 5 V C �i 1-� City l' v� S Gi' ( �lrr�,, C �'� ZIP 0�
❑ CW ❑ EW ❑ PTA ES /1 PTS Phone (��D ) �1` r~ `1 S River Basin Ins e
❑ OEA ❑ HHF ElIH �UBA ❑ N/A
Adj. Wtr. Body �<d ,1 nat
El PWS.
yes / �o PNA yes / o�
Closest Maj. Wtr. Body f t,Vw
Project/ Activity ize,10 t tl'Q Nc
1 (Scale: t % )'
k) length
tform(s) _
'latform(s)
gth
fiber
I Riprap length Jb
distance offshore 0
: distance offshore
Ildozing
��rWbc
'rrr h s-Y-A-
not sure yes no
im: n/a yes no
yes no
:tached: yes n
g permit may be required by:
ocal Planning jurisdiction)

NC Division of Coastal Mgt. Habitat Impact Coml
Applicant: ' per OLV4 � " y
Date:
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
FII
(Applied for.
(Anticipated final
(Applied for.
(At
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
dis
Habitat Name
Choose One
includes any
Excludes any
total includes
Ex,
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
ten
ternimpacts)
impact amount)
ternimpacts)
a r
kG
Dredge ❑ Fill Both ❑ Other ❑
aQ p
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

A
NCDE�IR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis
Governor Director
John E. Skvarla, III
Secretary
AGENT AUTHORIZATION FORM
Date: 4 /O -lei
Jame of Property Owner Applying for Permit: Name of Authorized --Agent for this project:
)wner's Mailing Address:
M7- Awty lfh,., tY
/3N tom % f//,U r.�i'ff31S�c.�
/"T, // Y iyS7o
'hone Number &/ 36L16 -f✓/j—e
Agent's Mailing Address:
6 �0kli� Q�IQUC\-� V)lr-,_5k-O
Phone Number��)
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
)r and obtaining all CAMA Permits necessary to install or construct the following (activity):
or my property located at
his certification is valid thru (date) UV r) , \�� Ohm leVt(XA
Property Owner Signature Date --

items 1, 2, and 3.
name and address on the reverse
can return the card to you.
s card to the back of the mailpiece,
front if space permits.
ressed to: SS 11 l
A. Sig lure (A—Wi—AAAWAddressee
xAgent
B. Receive by (Printed N me C. Date of Deliviory
0a4^o! && " -t-sl
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
II III
I� i I
I I
I I
I III II
I II
III
I I II
II'I
I
3. Service Type
❑ Priority Mail Expresso
❑ Adult Signature
❑Registered Mail-
11 ult Signature Restricted Delivery
El Registered Mail Restricted
0 9403 0603 5183 4336 67
Certified Mail®
iCertified
Delivery
Mail Restricted Delivery
❑ Return Receipt for
❑ Collect on Delivery
erchandise
lber (Transfer from servirp lahall
^^ Delivery Restricted Delivery
Signature ConfirmationT^'
til
L 5 0640 0006 3682 2277 r r lil Restricted Delivery
❑ Signature Confirmation
Restricted Delivery
I tuver zbbuu)
11, April 2015 PSN 7530-02-000-9053
Domestic Return Receipt
r delivery information, visit our website at wwmuspsxom®.
$3.30
Services & Fees (check box, add fee ass .rs)
etum Receipt (hardcopy) $ l� m rl�
etum Receipt (electronic) $
ertified Mail Restricted Delivery $ �i j„)Sfl _III - CIO
l_ III 1
dull Signature Requlred $ d {I@{i
dull signature Restricted Delivery $
'ge $0.47
.47
0470
12
Postmark
Here
(14/12/2016
T-T
U.J.-Postal
Service`"
C
RTIFIED
MAIL°
RECEIPT
Mail
Only
Domestic
For delivery
information,
visit
website at
www.usps.com .
MEN
Sour
ri
ro
—0
r1
C3
C3
O
I]
:I-
-0
C3
Lrl
C3
r
■ 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.
A. Signature
B. Received by (Printed Name) I C. D
SulwWc_ Ph\\_a). Sc_ H
1. Article Addressed to:
D. Is delivery address different from item 1?
If YES, enter delivery address below:

CERTIFIED MAIL. •-RETURN RECEIPT REQUESTED
DIVISION OF COASTAL. MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name; of Property Owner: 1CL
Address ofProperty: �1ll_v�i�? -- -
(Lot or Street #, Street or Road, City & Counry
Address: dress: Wb
Agent's Name A \'
Agent's phone
hereby certify that I own property adjacent to the above referenced property. The individual applying for
this ermit has described to me as shown on the attached-drawthe development they are proposing.
I'll1i tl: hin..t�i��;��1> 'an;tliRrif
1 have uo 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 COQstal
Management (OCM) In writing within 10 days of receipt of this notice. Correspgndence.should be
mailed to 127 Cardinal Drive Ext., Wilmington, NC, 28405-3845. DCM representggVes can also be
contacted at [phone]. No response is considered the same as no objection if you tip been
notified by Certified Ma A. �•» -- �-
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.
I do not wish to waive the 15' setback requirement.
�Property Own r nformation) \
•'�/7(r YN•ct - - -- v
A�_A_
Print or Type Name
etilincg Address
City/State/Z1p
telephone Nurnher
(Adjacent Property Owner Information)
Signrdure
Print or Type Name
Mailing Address
City/stir
Telephone Number

i
F-
r. I( r"\ 1 Q n. 1 1 N 1 -7 1