67107D - Pollard

CAMA / ❑ DREDGE & FILL KI.-;PTO 6710
MNERAL PERMIT 7/ty Previous permit# A B
INew ❑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 �(
❑ Rules attached.
t Name AWV Project Location: County
_-r� �.-ti.- tic%✓ % �')
Oq Ul '!,�'>A/ t/I r ! i Stated ZIP
E-Mail
Bd Agent /U l
❑ CW )UW lkn' PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
Street Address/ State Road/ Lot #(s)
r%
Subdivision
City % . L is 4�y/ GGC� ZIP
Phone # River Basin �A
Adj. Wtr. Body
OK
yes /� PNA yes / no Closest Maj. Wtr. Body N``J / rl-c—
Project/ Activity
(Scale: I /;r Z
:k) length
tform(s)
igth
nber
I/ Riprap length
distance offshore
K distance offshore
annel
is yards
'p r
Length
not sure yes
i
um: n/a yes
- r -
yes -;� ,TO
ttached: q /
permit ma be required 'lr'.� C
g P Y 9 Y /if/ � El See note on back regarding River Basin
.ocal Planning jurisdiction)

N D'evisi®n f Go stal .Mgt. Habitat Impact computer sheet
Applicant: v
Date: �— S 16
lication.
Describe elow the HABITAT disturbances for the app .
All values should match the name, and units of measurement found in your Habitat code sheet.
Fjoe
TOT,4L Sq: Ft. FINAL Sq.
A lied f
(Rpplied for. (Anticipated final (Applied
DISTURB TYPE Disturbance.total disturbance- total incluEx
Fincludes any Excludes any
anticipated any anticip
Habitat Name Choose One restoration restoratio
restoration or and/or temp
temp impacts) im act amount tem im a
Dredge ❑ Fill ❑ Both ❑ Other
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ElBoth
El
other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑.
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑�0

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAIVER FORM
Name of Property Owner:
n /n�
Address of Property: Z x _" % i �-L r3 t4 � y ,FS � E f
(Lot or Street #, Street or Road, City & County)
Agent's Name #:
Agent's phone #:
Mailing Address:
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. A description or drawing, with dimensions. must be provided with this letter.
(�I have no 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 (DCH) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wilmington, KC, 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no objection if Lou have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, do i i breakwater, boathouse, lift, or groin must be set
back a minimum dist a of 15' from my ar o iparian access unless waived by me. (If you
wish to waive the s back, you must initial the propriate blank below.)
I o wis ai4 the 1 ' ack requirement.
i do hot wish tb waive the 15' setback requirement.
(Property Owner Information)
Signature;,
I �L" O
Print or Type Name
(Adjac Prope Owner infor ation)�
Signature
Print or Type Name
C.)lAL&gsV
Mailing Address
Mailing Address

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONI1fllAIVER FORM
Name of Property Owner:
A 'J
Address of Property:
(Lot or Street #, Street or Road, City & County)
Agent's Name #:
Agent's phone #:
Mailing Address:
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 fihe development
they are proposing. A description or drawing, with dimensions must be provided with this letter.
6,1�I have no 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 (DCM9) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wilmington, KC, 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no objection if Lou have been notified by Certified Mail;
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.)
I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
zz�m
Signature
9 ,�,� v 0,LoM, P 0
Print or Type Name
(Adjacent Prope caner Information)
Sign tur
L H UC1S0 n
Print or Type Name
3 b Cl)'u gk?igV ?
_Mailing Address
23 y ICI W Co rn66r E31yd
Mailing Address

CEIRTiFIED MAIL � iRE URN RECEIP T REQUES4ED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORK
Name of Property Owner,
Address of Property
Agent's Name *-
Agent's phone #:
i.Lot or Street #. St,eet or Road, City & County)
Mailing Acdress:
hereby-ertify that I oven propery adjacent to the above-eferen:ed property. The indiv!dua
appiyirg for this parmit has described to me as shown on the attached drawing the development
they ars proposing, A description or drawtng with diriensiQns�must be rovided with this letter.
ha►e no objections to this proposa.. I i have objections to this propn,,al
!f you have obiections to what is being proposed, you must notify the Division of Coastal Ianagement (DCM) ;n
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Fart.,
WUmington, hlC. 28405-3845. DCM representatives can also be contacted at [phone], .No response ;s
considered the same as no objection i v have been notified by Certified Mail. ^�
WAIVER SECTION
understand that a pier. d=5�� breakwater. boathouse. lift. or g-oin must be set
back a minimum disc of t 5' from my ar'aa ofyiparian access ur ess waived by me. (If you
wish to waive the back. you must initial the appropriate blank belt.,-
RECEIVED
I do wis ive the 15 setback requirement. JUL 15
2016
I do not wish to wave the 15 setback requireme^t
;Property Owner InformaVon)
i
.)iRnature
DC&4 wu a►ti��,rr.. , NC
(adjacent Property Owner Infor ation)
,S`ign�atrre
Print or rvpe Name
Print .11, Type Name

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