67201D - Kelly

ICAMA / ❑ DREDGE & FILL `
iy �(„o
'• RENEAL PERMIT Previous permit#
lNew ❑Modification ❑Complete Reissue El 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 t L(x►
❑ Rules attached.
t Name �;C �q Ktl ��.( Project Location: County 9!aJ'O!:JL',; �k
I Z L; or S �� t J J� INV^I Street Address/ State Road/ Lot #(s)
�11iFJ� [tC State'.J(- `ZIP 46%1 �� j ��`� t A l'�J' ! 5 �,� �t `��
%b7 7 -3 Hsi 6 -47 <
O E-Mail Subdivision
edAgent (,,�,�I. tZ:C4.n-Y�Sp�• City r-(aiAe� z I .t G. ZIP eZ�
❑ CW )(EW XPTA ❑ ES ❑ PTS A G Phone # (�ie,) - a��� River Basin L U hA i
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ N/A
❑ PWS:
yes /, no , PNA yes / no
Adj. Wtr. Body C _U rcrt (nat /r
Closest Maj. Wtr. Body = ��
Project/ Activity 11�+N\,V = 1. + r
:k) length
■�■ �1'. ■■■■■■■�■■■®■■■�■■�■■
■■■�■■■■N■■`i■■r■®■■■■■■��r■�
igth
nber
I/ Riprap length
distance offshore
K distance offshore
annel
,ic yards
ip
;e/ Boatlift
dldozin�r
Length
not sure yes no
um: n/a yes no
yes (no
,[[ached: yes no
ig permit may be required by:
.ocal Planning jurisdiction)
-T'6 W (N A 4 1(6 & CA ❑ See note on back regarding River Basin

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: 1'<0. V �1 Vim/ V+ Permit #. vn b i
fv %
Date:
O
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
l
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 [IFill El Both El Other [IDredge
❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both Q Other ❑
Dredge 0 Fill 71 Both ❑ Other ❑

1 09/0812016 08,132 #849 P.0021004
AUGUSTA BACK 706 396 6357
MCA&
R
North Carolina Depatnerit of En*onnwt and Natural Resources
Division of CoasW Marwerrient
Bevedy Eaves Perdue James H. Greg Dee Fteetrw
Governor Director Seaetary
AGENT AUTHORIZATION FORM'
Date, September 7th, 2016
Name of Property Owner Applying for Permit: Name of Authorized Agent for this "ect.
Richard Kelly
Ownees Moiling Address
9 Michaels Watk
Martinez GA 30907
Phone Number 707) 303-4460
Will Richardson
Agent's Mailing Address:
3235 Seacrest Ave SW
gu ,gp!y NC 28462
Phone Number (910 1367-0335
I certify that I have suftrized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all LAMA Permits necessary to install or construct the following (activity):
Construction of new Stationary dock and general maint.
(my prop" located) at 112 lions Paw Dr. Holden Beach NC 28462
This certification is valid thru (date) November 2016
Property Owner Signature Date

DIVISION OF CO--ASrAL JyL4lAGEMENT
'I,DJAM-T RIPARMNL PROPERTY OVYi LER STATEN EM
I hereby Gatify that I own property adj scent tocv Is
(dame of Proerty Owner)
property looted at t t � l-� �z� s ��� < 0
(Lot, Block, Road, etc.)
in ,
(%terbody) (Town and/or County)
Applicant's phone #: j - _ '. ; LI, Mailing Address. .._.. N` . Y'i. o L n 1
luk's.y,jlnj &, Y"f 1
He/She has described to me as shown below the development he/she is proposing at that location,
and I have no objections to the proposal.
DESCRIPTION ANUOR DRAWING OF PROPOSED DEVELOPMENT:
(Individual proposiq, development must fill in description below or attach a site drawing)
frt�_OL t +ttw� �'�f.1 :r�c:� � °t"l ai�-�t�t?
If you have objections to what is being proposed, you most laotify the Division of Coastal Wimagement (D01) in Denting
within 10 da73 of receipt of this notice. Corrtspoodence would he mailed to 127 Cardinal Drive Ert Wilmington, NC
DCM 'representatives can also be contacted at (910) 796-721;_
No resaonse is considered the same as no oblectton if You have been nqU&d by Certifiers Ma=►
(Y opertr Ownerl�rormation) /
Signa%re
Point or Type Name
(Riparian Property Owner Information)
Signatu
S u �n-r-W..e S
Print or Type Name
lv—
Mailing Address j Mailing Address
Lk W3
City / S 2tp City / State / Zip

RECEIPT REQtt-ESTED
DIVISION OF CO -AST -AL KkNAGENIENT
ADJACn. -T RIPARIAN PROPERTY OW-,qxER STATFNMNT
I hereby certif� that, I 01,NM property adjacent to
s
�Iame of Property Owner)
property located at
(Lot, Block, Road,
t
on M
l-"t , t , t N.C.
Applicant'
(Waterbody) (Town and/or County)
s phone#,
MaiLing Address:
HeShe has described to me as Aown below the development betshe is proposing at that location,
raid 1 hive no objections to the proposal.
DESCRIPTION AIND/OR DRAWLNG OF PROPOSED DEVELOP ANT:
{Individual proposing development mustrdl in description below or attack a site drawing-)
Tf you have objections to wbat is being proposed, You must notify the Division of Coastal Msuagetueui within 10 days of recri t of this aottez CM) Upwriting
P Correspondence should be mailed to 127 Cardinal Drive Ext. WilmingtonNC
DCM representatives cAn also be contacted at (910) 7967215.
No reSDQI18e iscansidered th
is considered =114-red the Same as no objection if you have been notified by Certified Mail
( Property Owner Formation)
Signature
Print or Type Name
Mailing Address
\A
City S;� zip
,.�Wpariau Pro rty, er Information)
.-a n
Print or Type Name
MaiFng A�ddress
I C4--
City I State 1 Zip

VP I 8x1b
New Stationary Dock -1- 12x18
281FT Scope of 1Nork:
Disconnect existing utilities
Remove existing stationary d(
Gonstruction of new stationan
Utilities to be reconnected by
UU
E Xistin(i Structures