66629D - Bond

CAMA / ❑ DREDGE & FILL
• 1
GENERAL PERMIT
New ❑Modification ❑Complete Reissue El Partial Reissue
Tr f 6 A
Previous permit #
Date previous permit issued
B
zed by the State of North Carolina, Department of Environment and Natural Resources —7
�astal Resources Commission in an area of environmental concern pursuant to 15A NCAC L
` �� ^ L El Rules attached.
Name =\) ,`�` Project Location: County 1/4 r'w`;w1 C �-
0 Street Address/ State Road/ Lot #(s) -7
n,;t C. Cl ( V-N S ZIP
'tAAA%,
y) (`�1t� 5� O -Mail" , Subdivision
�w l �ity11��� Lie
:d Agent N V ( ['( 1�� 1 q t Pn t ZIP t
❑CW C tW E*TA` El ES ❑PTS Phone # (���) r� 1' t116"�� River Basin Low t
❑ OEA ❑ HHF 6 IH - ❑ UBA ❑ N/A Adj. Wtr. Body (� ` C nat
❑ PWS:
es / PNA yes /(n� Closest Maj. Wtr. Body A—]
Project/ Activity
k) length=y �(
tform(s)
'latform(s)
gth
length
offshore
offshore
is yards
p
,e/ Boatlift
Ildozing
i2
Length U
not sure yes no
um: n/a yes
yes
atached: yes no
ig permit may be required by:
.ocal Planning lurisdiction)
-T6w1\ 0
C ( i v1
{
(Scale: — <
❑ See note on back regarding River Basin rt

NC Division of Coastal Mgt. Habitat Impact Com
Applicant: �O�V cis
Date: 0 C 6 7 /�O(1,
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.
(Af
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
ter
tem impacts)
impact amount)
ternimpacts)
arc
Dredge ❑ Fill ❑ Both ❑ Other
f
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

"�-
iA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
IcCrory Braxton C. Davis
ernor Director
John E. Skvarla, III
Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FORM
Date:
of Property Owner Applying for Permit:
Ywr✓ 5 /1 �®Kb
�r's Mailing Address:
e Number (910 ) S7,1r--ZZ 91
Name of Authorized Agent for this project:
Agent's Mailing Address:
Phone Number �7q- uyS
Ify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
id obtaining all CAMA Permits necessary to install or construct the following (activity):
G 1< RgTI Ac COMIZ ASS T -
ny property located at 1,947 E �t�lt�i� SlJ,JS�l'B�/� �G Z/&A
certification is valid thru (date)
Property Owner Signature
Date

lete items 1, 2, and 3.
our name and address on the reverse
t we can return the card to you.
I this card to the back of the mailpiece,
the front if space permits.
Addressed to:
�i—
I� Wd�l�,f v-)'7CA �ZcI
A. Signature
X ❑ Agent
❑ Addressee
B. Received by (Print e Name) C. D to of Ielivery
D e ddr dffferent`frort<i 1? ❑ Yes
If Y enterldelivery addre be] w: ❑ No
IIII'I I'll I'I I I I I I I I I III I' I II III I II III II III 1F Servicellype ❑ p ority Mail r sO
11AAdult Signajue egisterd Mail"
❑ ult SignatureAjegir�V.J(Delivery Registered Mail Restricted
►590 9403 0603 5183 4336 98 Certified Mail® _-� Delivery
%Certi Mail Restricted Delivery ❑ Return Receipt for
❑ Collect on Delivery M chandise
Number (Transfer from cand'o r�ti kr ,elivery Restricted Delivery gnature ConfirmationTM
2 2 4 6 ❑ Signature Confirmation
7 01, 5 0640 0006 3682
Restricted Delivery Restricted Delivery
(over$500)
3811, April 2015 PSN 7530-02-000-9053 Domestic Return Receipt
Postal
© RECEIPT
�omestic Mail Only Er CERTIFIED MAILP RECEIPT
.11.19 m Domestic Mail Only
• ti
a ti
212,7kL. •WE information,delivery ' T
ified Mail Fee �L USE
f3.36 r u a g
1470 co Certified Mail Fee $3.30
a Services & Fees (check box, add fee re) 12 m $ 1
ietum Receipt (hardoopy) $ • Extra Services & Fees (check box, add fee aaWro@t(e)
ietum Receipt (electronic) $ Sfl _ 1 Ifl Postmark ❑ Return Receipt (hardcopy) $
:ertified Mail Restricted Delivery $ — Here 0 ❑ Return Receipt (electronic) $ # • Utk Postmark
Wun signature Required $ t r. nn C3 ❑ certified Mail Restricted Delivery $ 1 1) - 1l1 � Here
Wuh Signature Restricted Delivery $ ��— Q ❑ Adult Signature Required $ Sri _ fill
age (1 , 47 i= ❑ Adult Signature Restricted Delivery $
Postage
IPostage and 04/12/2016 -B$ $4.47 (14/12/201b
F�gs
7b . 47 C3 Total Postage and FT$ . 47
Ln
1S1�i�(jZ1 `1mCl�k Yn Se�nt
-------- _uitwBm
n
S eZaAvf._.��, a---- ---------------------------------- N----Y---------------ty, Kate,
272ou
■ 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 theliftint if space permits.
r,. *Rb
❑❑ Ag�tX �KddresseeB.d N C. Date( 2I��l�l 7
1. Article Addressed to:
Vkt��`� 1)AU li�z
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: Q. W6

CERTIFIED MAIL. RETURN RIrCElPI RgQUESTED
-- -DIVISION OF COASTAL. MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
a mac`
Name of Property Owner: Ja'm� - - --
Address of Property:
(Lot or Street Il, Stt'
Araent's Name
Agent's phone #: „ S�� �t L E
or Road, City & County)
Mailing Address: �Ct c
1 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.drawinq ,the development they are proposing.
I 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 Coastal
Management (QCM) In writing within 10 o
s of receipt of this notice. Corresy9np►er►ee•shauld be
maned to 127 Cardinal Drive Ext., Wilmon, NC, 28405-3846. DCM represent49vel; can also be
contacted at [phone]. No response Is considered the sane as no objection If you hV$ been
notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwlater, 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.)
do wish to waive the 15' setback requirement.
do not wish to waive the 15' setback requirement.
XProperty Owne It formation)
SigrralrrPr� �- --_�
Pint or Type Name
Mailing Address
I, 6\AA
J�
cityFstatelzlp
169.
telephone Number
— (Adjacent Property Owner Information)
&!::Sign I _re'e __.___`
on —
Print or Type Nome
Mailing Address
City/.Statelzip
Telephone Number

CERTIFIED MAIL •-RUTURN RECEIPT Rj QVf;ST�C)
--DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property: I� 1 \-J—���� tl.�_. --` _..- t
(Lot or Street #, Street or Road, ity & CounTy) -
Agent's Name IL C�ZL(( t6!1 Mailing Address: t� �C,
Agent's phone #: �_.—�S_! n-6 S__ \ rl SI (' Ck�t�N �
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. drawin the development they are. proposing.
A + 1�iti lla�fs t1i ' ieif'n's� ,ViI EFrs'df ` i�IC "' InYt " sf ` `rb r� 1 ' �I,
�v/ I lutve no objections to [his proposal. 1 have ol�lections to this propusaL
If you have objections to what, is being proposed, you must notify the Division of Coastal
Management (QCM) in writing within 10 days of receipt of this notice. Co►responclence.should be
mailed to 127 Cardinal Drive Ext., Wilmington, NC, 28405-3846. DCM represent#,fives can also be
contacted at [phone]. No response is considered the same as no objection if you hV0 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.
do not wish to waive the 15' setback requirement.
(Property Owner Ir ormation)
Si�rralrn•rr
Print or Type Name
Mailing Address
Cityistateizip
-rolephone Number
-- (Adjacent Property Owner Information)
Signnlr►re __
Print of pe NAme
Mailing Address
City/state/zip
1 eleWR; a Nt►mber
R D -- -
1-1zI 9

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
----DIV+SION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: --
Address of Property:
(Lot or Street #, Street
Agent's NameL:r��C�t6r
Agent's phone #: C� q L 1�
or Road, City & County)
q
Mailing Address:
cl1 NZ`I y
1 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 _dra�rtng the development they are proposing.
A d�..115tiott,tir����«'frr'd� `��>lf�rtcii IIbff6MW`r Wdam, vw�
ryvou
t hnveno objectionsto this proposal. Ihaveobjectionstothisproposal.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. Correspgn0ence.should be
mailed to 127 Cardinal Drive Ext., Wilmington, NC, 28405-3846. DCM representooves can also be
contacted at [phone]. No response is considered the same as no obJectlori ff you h been
notified by Certified Mall.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin mast be set. back a
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to waive the
tbacI you must Initial the appropriate blank below.)
do wish to waive the 15' setback requirement.
do not wish to waive the 15' setback requirement.
(Property Owner h formation)
sign ure
Print or Type Name
Mailing Address
City/State/Zip
Telephone Number
(Adjacent Property Owner Information)
Si nnlirre �`
Pint or Type Name
6 Ne /W 2210
Mailing Address
//I/
City/State2ip
Telephone Number

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