66667D - Frank

CAMA / D DREDGE &FILL � % J�// �' A B
WNERAL PERMIT K / / (� Previous permit #
I�Jew ❑Modification ❑Complete Reissue El Part eissue 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
�.�,, ^ ❑ Rules attached.
Name < � ' ` �,` Z Uv (l�� Project Location: County—(; VV,-, ,, F
0- N CQ state '�, ZIP 'J\q '� C
03 'M- Ilit I E-Mail
A Agent (�Y�A (MsbV C412 rn
❑ CW ❑ EW ❑ PTA KES [OPTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
,es / no PNA yes /
Project/ Activity , c A Ate a J � O%e GA a -
k) length
tform(s) _
'latform(s)
gth l
fiber
i
Riprap length
distance offshore 0'
distance offshore
is yards
Length 1� C
not sure yes
Jm: n/a yes
yes
ttached: yes
g permit may be required by:
.ocal Planning jurisdiction),,)
Street Address/ State Road/ Lot #(s)
Subdivision
City .(I)U (Lin U t bi ZIP(
/14fio e # (- r) -l`I< °I DT; River Basin �. IiWA
Adj. Wtr. Body A VA a, \ (nay
Closest Maj. Wtr. Body A-1
(ScaJe:1 �
_Ot ❑ See note on back regarding River Basin ru

NC Division of Coastal Mgt. Habitat Impact Con
Applicant: C (AJ� � �/ V
Date: (I A'0
V ( (,(
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
F
(Applied for.
(Anticipated final
(Applied for.
(i
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
d
Habitat Name
Choose One
includes any
Excludes any
total includes
E
anticipated
restoration
any anticipated
n
restoration or
and/or temp
restoration or
t(
temp impacts)
impact amount)
temp impacts
a
Dredge ❑ Fill Both ❑ Other ❑
1 006
000
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both 0 Other ❑

NCDENR
North Carolina Department of Environment and Natural Resources
Division -of Coastal Management
'at McCrory Braxton C. Davis
Governor Director
John E. Skvar.
Secretar
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FuKm
Date:L_)-c-AL�
3,Te of Property Owner Applying for Permit:
Nner's Mailing Address:
Q,S"/�, 1J Ke✓W-�c -
T J [) t-e nee :� S C
lone Number 4'1� -� oZ�—�] q C
Name of Authorized Agent for this project:
Agent's Mailing Address:
I t3pc_,CA Dr 3-
Phone Number (TO )79 - c'I (", q( 1
:ertify 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):
)r my property located at
If
its certification is valid thru (date) ILILn
*
Property Owner Signature Date

■ 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.
1. Article Addressed to:
C�ac-�►� VAS
A.
B. Received by
O-D—A )
J
C. Date of Delivery
D. Is delivery t(ddress different from Rem 1? ❑JI'ea
If YES, enter delivery address below: No
II I'lll'I IIII I'I I I I I I I I I III I' I II III I I I (III I III 3. Service Type ❑ Priority Mail Express®
❑ Adult Signature ❑Registered MaiIT'"
❑ Adult Signature Restricted Delivery ❑ Registered Mail Restricted
9590 9403 0603 5183 4336 29 ❑ Certified Mail® Delivery
❑. Certified Mail Restricted Delivery ❑ Return Receipt for
El Collect on Delivery Merchandise
2. Article Number (Transfer from service label) ❑ Collect on Delivery Restricted Delivery ❑ Signature Confirmation —
tail ❑ Signature Confirmation
7 015 0640 0006 3682 2 3 0 7 11 Restricted Delivery Restricted Delivery
PS Form 3811, April 2015 PSN 7530-02-000-9053 Domestic Return Rec64
PostalU.S. Postal Service - i -�i U.S.
CERTIFIED MAIL@ RECEIPT 0 +. •niy o
rU Domettic mail •
m
NAq ru
CIV ertified Mail Fee � 1 I,0U IM 4 f
$3.30 1 i471 .O Certified Mail Fee
s (I m $ $3.30 0470
Extra Services &Fees (check box, add ree ppp tad 1
❑ Return Receipt (hardcopy) $1 I _ _ Extra Services &Fees (chaGr bcx, add lee as �11
❑ Retum Receipt (electronic) $ �, n�j (j 1_
❑ Return Receipt (hardcopy) $ 1
❑ Certified Mail Restricted Delivery $ Postmark t� El Return Receipt (electronic) $ to nil
t fy n t ii — —....� ,r— Postmark ❑Adult Signature R $ `— Here t7 ❑Dertfied Mail Restricted Delivery $ Required �i 1.,, ; 0 �Aduk Signature Required $ �� Here
QAdult Signature Restricted Delivery $ :Tr7�-
❑Adult Signature Restricted Delivery $
'ostage O Postage
'o ostageand Fegs (1 6/14/� 2016 —0 $ $0.47
$.47 o Total Postage and Fees 06/14/2016
$ $6.47
r �\\
rSent
----- - ----r-1
- T 1 \ `Gt n
t.� c�a c Q
------------------------------------
r�z
■ Complete items 1, 2, and 3. A. Signature
■ Print your name and address on the reverse X !�J Agent
so that we can return the card to you. ❑ Addressee
■ Attach this card to the back of the mailpiece, B. Received by?Printed Name) Date of Delivery
or on the front if space permits. - 1
1. Article Addressed to: D. Is delivery address different from item 1? ❑ Yes
.

CERTIFIED MAIL. RETURN RL:CEIPT Rl q Et1 STED
----DMSION OF COASTAL. MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIF'ICATIONIWAIVER FORM
Name of Property Owner: _LLB` �_nJ _ ��d`� _—•------ -
Address of Property:_��
(Lot or Street #, Street r Road, City & Counlyj--
Agent's Name
Agent's phone #: %k'J 5-1CA- �VAS.
Mailing Address:
\{(0Y
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_dramdn-the development they are proposing.
I htrve uo objections to this proposiil. - __- I I have objections to this proposfll.
if you have objections to what. is being proposed, you must -notify the Division of Coastal
Management (OCM) in writing within 10 days of receipt of this notice. Corresygnoence. should be
mailed to 127 Cardinal Drive Ext., Wilmington, NC, 28405-3845. DCM repre8e04>tit 08 can also be
contacted at [phone]. No response is considered the sa►ne-as no objectlort tf you hl been
notified by Certified Mail. _
WAIVER SECTION
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 tMgg Initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
I do newish to waive the 15' setback requirement.
(Property Owner information)
Signature
Print or Type Name ^
Mailing Address Y
Ch—
cityl9ftfolzip
I `k�j)-- 2Z(- `rl
(Adjacent Property Owner Information)
Signurrure
Print or Tie
�1. ���n�c a e�k__�._. _ _-•---- ---
Mailing Address
-C►tyistat )7 p
Telephone Number
1"eliphone Number

CERTIFIE MAIL RETI�JRN R -C_GIP QIJ REESTE1)
--DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:0���5-- --�
(Lot or Street #, Street r Road, City & Coun Y1
Agent's Name #G%Lksk
Agent's phone
Mailing Address. &44 \-VS16
256\1(oY
hereby certify that I own property adjacent to the above referenced property. The individual applying for
this hermit has described to me as shown on the attached_drawtn the development they are proposing.
y' I hitve Ito 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 (I)CM) in writing within 10 days of receipt of this notice. Correspondence -should be
malled to 127 Cardinal Drive Ext., Wilmington, NC, 28405-3845. DCM represetltq*os can also be
contacted at [phone]. No response is considered the same as no objectlorl IT you irk been
notified by Certified Mail. --
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin roust be set. back a
minimum distance -"'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.
I4o-Oq wish to waiveire 't5' setback requirement.
(Property Ownor Information)
Sit;nalrn•�c
Print or Type Name
Mtriling Address ^!
VV:
city)-qW0 z0
Tolphone Number
(Adjacent PropeoYlOwner Information)
Signulru•e
Print or Type Name
Owl
Moiling Address
N e _nlZss
citylstatelzip
Asp--�:��____
Telephone Alumber

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