67919D - Gilliland

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: Permit #:LKV
Date:
I
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 amoung
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount)
Dredge ❑ Fill ❑ Both ❑ Other
V�
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 171 Both ❑ Other ❑

3ayment Proccessing Confirmation
Date Received F 12/15/2016
'heck From (Name) American Marine Construction Inc
Name of Permit Holder Kerry Gilliland
Vendor First Citizens Bank
Check Number 86483
Check amount $200.00
Multiple Permits No
Major/Minor
Permit Number/Comments GP 67919D
Receipt or Refund/Reallocated TM/2860D

:Pherson, Tara
n: Gilliland < kerrymd @triad. rr. com >
Wednesday, December 14, 2016 8:04 PM
MacPherson, Tara
Tommy Perry
lect: Dock @ 240 East Bay Street - SPT
)rtance: High
Tara,
uny Perry asked that I sign and send you this document.
se let me know if it did not come through.
*s,
y (Gilliland)
fir: A rarer ArUs.il�r.rws�F
Yrirr.r�wa�rrrrr
�wiwswnwe:
�erwwwx�rrr� .
�ws� xxw •M1#tir
M1�4MIIMAMJi1wNt .
saidn.�'1w.r_.+. Curti
�+ssrr111C-+tSY4+1�
�..n,rwra.r�s

N' .
fame of Individual Applying for Permits K z + I
kddmu of Property
t L-ot or Street 4. Street or Road)
Li 61
'Ciry and Cowty
hereby certify that I own property adjacent to the above- reference a properti°. The individual
applying for this permit has described to me as shown oathe attached drawing the deveiopnxsRthey
ire pTorosing- A descriation or drawing, with dimemlons. should be crovided with this let+ec
have no objections to this rropos.:i
if you have objections to what is being propoSed• please write the D" (jIvn of Cbfisia�-
Management, 121 C.3rditral Drive Exteu3ion, Wilmington, NC 28405 or c:+il 911796-T)-G
wirbia 10 days of receipt of thitr notice. No response is considered the some as no oWwtianif
you have been notified by Certifled Mail.
w AiVER SECTION
I understood that a pier, dock, moring pilings, breakwater, boot rouse or boar. lift mustbeset
bck a minimum distance of 1:' from my area of riparian access - unless waived bti she. i lfyou
wisb to waive the setback, you must initial the appropriate biank below
do Wise to waive tha i 3' setback renuirer-A---
1 do noi wish to .vaivc the i 3' setback rca=trcTcr
Date
xf- A+:MA

■ 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'� e �acl�
A. Signature
❑ Agent
X ��—� /��� ❑ Addre
B. Rec ' ed by (Printed Name) C. D q, T'TIi
D. Is delivery address different from item ? ❑ Yes
If YES, enter deliver E&w: ❑ No
DCM WIUAINGTOfO Nt'.
DEC 0 2 20%
II I'I'I'I IIII ICI II II I I (IIII II III I I II I II I I I I III
9590 9403 0319 5155 0619 08
I
3. 6ervice Type
Adult Signature
0 Adult Signature Restricted Delivery
0 Certified Mal@
0 Certified Mail Restricted Delivery
❑ Collect on Delivery
❑ Collect on Delivery Restricted Delivery
- --� -
❑ Priority Mail Express(E)
❑ Registered Mail-
R
O Registered Mail Restricted
Delivery
❑ Return Receipt for
Merchandise
Signature Confirmation-
❑ Signature Confirmation
2. Article Number (Transfer from service label)
7 015 1520 0001 6 7 6 9
6938 restricted Delivery
Restricted Delivery
PS Form 3811, April 2015 PSN 7530-02-0004053
■ 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:
Li-� ()t- s-0u-��,Po
l E� --49 0 or-{i, aL,� (f s-4 -
5��, Poft r) c, ay61
Domestic Return Receipt I
A.
umtiw
❑ Agent
'• � ❑ Addressee
d by (Printed Name) C. Date of Delivery
WT44A�- 11.3-
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
RECEIVE,
DC-M WILMINGTO' N. N-
I � 2016
�El Exp. .>ervice type Priority ress@
IIillllllIIIIIIIIIIIIIu111�IunInlmill11w I�Aduflr.qi �at— -- .. _-.

0
c]-
3•
�oo4 o�+/cyr�r� A c-, p�Jlre �CcesS
o