67295D - Kelly

�CAMA / ❑ DREDGE & FILL J�t / )
I07 A B
�ENERAL PERMIT Previous permit #
lew ❑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 15A NCAC
❑ R es ttached.
t Name f Project Location: County
e ' Street Address,/�St`ate Road/ Lot #(s)
% State ZIP_ (O C 1 �1• �, _1,���'�1
E-Mail Subdivision
ed Agent
❑ Cw C�R7
❑ OEA ❑ HHF ❑ IH
❑ PW_5:
yes /j no PNA yes
Project/ Activity
A) iengm_
tform(s)
Platform(s)
igth
nber
I/ Riprap I
distance
( distance
annel
is yard?
P
�Boatlift V
Jm: n/a yes
yes
ttached: yes no
g permit may be required by:
ocal Planning jurisdiction)
no
❑ USA ❑ N/A
C
Phone # ( )
Adj. Wtr. Body
Closest Maj. Wtr. Body
a
ZIP
River Basin
(Scale:
I
❑ See note on back regarding River Basin r
la,
I^. . ,P% Ir./l . I. f 1w-11

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applican I Permit #.
Date:
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/or
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 ❑
-

)ayment Proccessing Confirmation
Sate Received 12/19/2016
:heck From (Name) F and S Marine Contractors
flame of Permit Holder Stan Kelly
Vendor PNC Bank
Check Number 5935
Check amount $200.00
Vlultiple Permits No
Vlajor/Minor
Permit Number/Comments GP 67295D
2eceipt or Refund/Reallocated TM/3461D

Pat McCrory
Govemor
MW
LOP AA. A
North Carolina Department of Environment and
N.C. Division of Coastal .Manager
AGENT AUTHORIZATION FOR
Date:
Name of Property Owner Applying for Permit: Name of Authi
C>wner's MalllnjxAddjpss:,, f� Agent's Maillnt
W���yroN'�ac.evU >\; P.O. Box868
Emai:' Sn �.itCS«`� Wrightsville Beach, NC 28480
Phone'- _ 336,- 3c;tgY � y Phone ( -�—
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
J�RECEIIVED
CM WILMINGTON, NC
DEC 1 4 2016
for, ?jW obtaining all CAMA Permits necessary to install or construct the following (activity):
For my property located at
1,6, ZSYWi AANewe# /Ao•
This certification is valid 1 year from (date) `b`� '� t `� $ea�3��j`L
�Ic�9 1g�012
Property O r signature L I ���� f J�al �Dy��,►�

CERTIFIED MAIL. • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property owner: � 1i n kL 'A]
Address of Property: %fit
(Lot or Street #, Streef or Road, City & County)
Agent's Name #: �- �� i1�,; n Maiing Addrees"s:�� , �1 ��►Z+ ��
Agent's phone #:%�'' $G-C :� 11��tt y/► ltr7u !Ji_ 1�iTit t > Z �ti �Ic1
t hereby certify that 1 own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown an the attached drawing the development
3 the y�aree Pr ng. A description or drtw+rinta with danensions must be Provided with ,trhis letter.
I he no objections to this proposal. I have objections to this proposal.
1 fl p
_�.��1 �LrP!'1N rxts��3t�
lFyou have I ecNans to what /s bekM proposed, you must notify the Wston of Coastal Mansgemer►t (DCM) In
wilting wM*110 days of receipt of this notice. Correspondence should be matted to 127 Cardinal Drive Ext.,
BYNrnhrgbn, NC, 28: W38e& DCM reprrosenteaves can at" be contacted at [phone]. No response is
considered the same as no oblectior► Nyou have been nodfad by Certilkd Mall.
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.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property "Owne5.•Ipformatlon) (Adj nt Property Owner Information)
Nj-
Signs tyre r Signature
.5,ralr- pi. -I 1ji
Print or Type Name
"444 6podd
Mailing Address
�# 1JA%/l)6
Print or T pe Na
1 � ��.
Mailing Address f /

feet 200
�ters 60
cllze rol, A/c