67267D - Carter

CAMA / ❑ DREDGE & FILL Y'L_ D f G M' 4 `
j I I I �C) A B
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aENERAL PERMIT Previous permit #
,New ❑Modification El Complete Reissue El Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources 77
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
,,)) ❑ Rules attached.
Name . S ��` .��� tfC' Project Location: County sec .J qo o0ye,,r
C(A)
State AJ( ZIP $�t
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E-Mail
ad Agent�t��n
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❑ CW
XEW
)(PTA ❑ ES ❑ PTS
❑ OEA
❑ HHF
❑ N ❑ UBA ❑ N/A
❑ PWS:
yes / no
PNA
_
yes / no
Project/ Activity_
I� a f
:k) length
tform(s)
Ilatform(s)
igth
fiber
/ Riprap length
distance offshc
c distance offsh
annel
is yards
MOM
ROM
Street Address/ State Road/ Lot #(s)
Subdivision
City ZIP
Phone # ( ) River Basin e f K
Adj. Wtr. Body On LCj Y1► I
Closest Maj. Wtr. Body
(Scale: N: f •'
❑ See note on back regarding River Basin ru

Krory
,emor
NCDENR
North Carolina Department of Environment and Natural Resources
N.C. Division of Coastal Management
AGENT AUTHORIZATION FORM
John E. Skvarla, III
Secretary
Date:
of Property Owner Applying for Permit: Name of Authorized Agent for this project:
!r's Mailing Address:
�'.►►�a1��.li
/ra'Li�
Agent's Mailing Address:
•
• • Ii
Phone
fy 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):
?^�, �lJi ��'; �jc''fi 9#x-; i
� y lfts��r�r d Al"), ', 1rf�
iy property located at
:ertification is valid 1 year from (date)

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: 110ST j (lr•='+�" �
Address of Property:
�`� `�n"��r„ //• Li./A/6 .nJllirT �fNi� r l��d )
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(Lot ?Z&e�r�
Agent's Name #: �- ��i�l i PO. BMAdd2ress:
1N
Agent's phone #: ri9htSvil1e Beach, '
C
0) 256
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 oposing. A description or drawing, with dimensions, must be provided with this letter.
I jh�avel no objections to this proposal. I have objections to this proposal.
llltff you have o jections to what is being proposed, you must notify the Division of Coastal Management (DCM) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Dive Ext.,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the some as no objection if you have been notified by Certitled Mail.
WAIVER SECTION N / 1
I understand that a pier, dock, mooring pilings, breakwater, bo se, 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
Signature
Print or lype Name
l�, A (j - L t j
Mailing Address
(Adjacent P(pperty O ner Informatioq) /'
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S7attireI/
Print dr Type Name
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Mailing Address
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F
stal Service"''IFIED MAIL° RECEIPT
Mail Only
ry information, visit our website at www.usps.como.
1
Certlfied Fee
Postmark
0
Return Receipt Fee
(Endorsement Regwred) �jl_I. (IQ
Here
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ResMcted Delivery Fee
(Endorsement Required)
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$0.
Total Postage & Fees
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Sent To
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Box i�POBox No. . �►0..31� W,ar 5�
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City State, ZIP+4 j0�� 6 �n��" 9
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P.O. Box 868
Wrightsville Beach, NC 28480
(9101 256-3062
RECEIVE
OCT 18 2016
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