67161D - Etheridge

CAMA / ❑ DREDGE & FILL
rt A B
'EN ERAL PERMIT �" �� Previous permit #
New ❑Modification ❑Complete Reissue []Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources —�!
oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC � / b o
c ❑ Rules a h
Na e At ¢ ri ► Yw('/1r l J !-e 'v _ Project Location: County
< Street Address/ tate Road/ Lot (s)
kA%1 State zip � LA �tAl -
t� )
ad Agent
❑ CW ElES ElPTS
❑ OEA IJ HHF tA
❑ UBA ❑ N/A
❑ PWS:
res / ry ) PNA yes /jnc�
Project/ Activity
:k) lengthT��
tform(s) H�
'latform(s)
er(s)
igth
fiber
/ Riprap length
distance offshor
c distance offish re
annel
is yards
P
s/ Boatl
4"c —
Length
not sure yes
um: n/a yes
yes
ttached: yes
fig permit may be required by:
.oval Planning Jurisdiction)
!OWVN
Al - .1 I ,
Subdivision
City �� _ q q Cq ZIP_��
s Ph ne # River Basin
Adj. Wtr. Body a V< nat 11
Closest Maj. Wtr. Body
(Scale:'
❑ See note on back regarding River Basin ru
L _l - 1, 1 n.- I

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: V e 4 f ��j � Permit #: _
Date: � �71
ae6/cb/� 0 (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.
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/o
temp impact
amount)
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 ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

NCDEE R
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
at McCrory Braxton C. Davis
3ovemor Director
John E. Skvarla, III
Secretary
AGENT AUTHORIZATION FORM
Date:
me of Property Owner Applying for Permit: me of Authorized Agent for this project:
mer's Mailing Address:
p o� 113el(
TI�t�0i7- �� .o�f-7Z
one Number Y1,0 ) 4 4,'0 - 7e6 %
Agent's Mailing Address:
4. \ t a.C1_61 p, S�
2�`tCo�
Phone Number (��D 1 �0�{0- 76G-1
�rtify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
and obtaining all CAMA Permits necessary to install or construct the following (activity):
r my property located at 'i1tf Gp2>SFr" daCGr4/r_T-ram AM
C� /VG
s certification is valid thru (date)
Property Owne a Date

gems 1, 2, and 3. A. Signatur
:,'
lame and address on the reverse X
can return the card to you.
card to the back of the mailpiece, B
.
ont if space permits.
ssed to: D.
If YES-, Vrtla
❑ Agent N,
❑ Addressee T �'
Date of Delivery
from Rem 17 ❑ Yes b
ass below: ❑ No
7015 0640 0006 3682
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3. ervice Type
❑ Priority Mail Express®
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❑Registered Mail -
signature Restrict elivery
O Registered Mail Restricted
19403 0603 5183 4335 13
ad Mail®
❑ Ce ad Delivery
Delivery
❑ Return ReI elpt foriF
1
per (transfer from service label
❑ Collect on Delivery
❑ Collect on Delivery Restricted Delivery
Merchandise
Signature Confirmation
❑ Signature Confirmation
tJ
,T v
i 0640 0006 3682
❑ Insured Mail
Restricted Delivery
2444 o�l Restricted Delivery
Restricted Delivery
Restricted Delivery
1, April 2015 PSN 7530-02-000-9053
Domestic Return Receipt
t
7015 0640 0006 3682
items 1, 2; and
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: +
11s��.Q�tCXA
\a,n\- 216 BIZ

CERTIFIED MAIL. RETURN RECEIPT REQUESTED
---DIVISION OF COASTAL_ MANAGEMENT
ADJACENT RIPARIAN PROPERTYOWNERNOTIFICATIONIWAIVER FORM
Name of Property Owner:-
i�u
Address of Property: `_►f- 5� QCfl 1 C�C_ntcaC
r( (l_ot or Street ll, Street or Road, City & Couniy-j `_
"V%�tja\t5� I +tc H %),q MallingAddress: X% &(401Agent s Name•la+: .�.._..�_.� �
��
Agent's phonell:
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 drawirV the development they are proposing.
d d 1t1. tl►b'fA�6i1)i>S't�t���iYr�It`�a'11Ir11�PlEts�i(fitt�.
1 have no objections to this proposal. t have objections to this proposal.
If you have objections to what Is being proposed, you must notify the Dlvlslon of Coastal
Management (I)CM) In writing within 10 days of receipt of this notice. Corresp9n0ence.should be
mailed to 127 Cardinal Drive Ext., Wilmington, NC, 28405-3845. DCM represe074*08 can also be
contacted at [phone]. No response Is considered the same as no objection !f you M been
notified by Certified Mail.
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
setback, you must initial the appropriate blank below.)
1 (10 wish to waive the 15' setback requirement.
I do not wish to waive the 1 S' setback requirement.
(Property Owner I iformation)
b'it;u«hne
Print or Type Name
Mtadintd Address
�ht�eu�ll� k\A ZVN'72.
citylstatelzip
C�Vo_-6\_caZk�to`t
1 elephone Nu►nher
(Adjacent Property Owner Information)
Signahire
_.__. Piint or Type Nta e
Mailing Address
citylstato/Zlil
Telephone Number

CERTIFIED MAIL • RETURN RECgIP1 KgUESTED
--DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPAR\RIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property: CDU rA_ 6� c � --1 �ma4t`k
(l.ot or Street 8, Street or Road, City & Countyj _
Agent's Name ZL , co V\5 r1 �c,� �*� Mailing Address:
Agent's phone
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.
I lutve oo objections to this proposol. ._ _ I hove objections to this proposal.
if you have o4joctions to what, is being proposed, you must notify the Division of Coastal
Management (UCM) in writing within 10 days of receipt of this notice. Corresognflonce.should be
mailed to 127 Cardinal Drive Ext., Wilmington, NC, 28405-3845. DCM representq*os can also be
contacted at [phone]. No response is considered the same as no objection if you h" been
notified by Centlfled Mall. _ —
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boatixXHW, lift, or groin roast 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.
I do notwish to waive tiie 15' setback requirement.
(Property Owner I rformation)
b'i1;TutluTe
{''Tint or T ypo Name
Mailing Address
��.►�eutlt� -_1�� 2-vi-72--
crryisrAr�izip
lolephone Number
(Adja Prope nor orma on)
-------- Sign n'e
Print or Type Name `
---. Madill Address -----
Citylsttatelzip
Telephone Number

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