66640D - Pascholoudis

�CAMA / ❑ DREDGE & FILL `� 61711�
AGENERAL PERMIT Previous permit#
gNew ❑ Modification []Complete Reissue ❑ Partial Reissue Date previous permit issued
>rized by the State of North Carolina, Department of Environment and Natural Resources rr
Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
❑l les attached.
it Name /Q /1 �i' r� QJ1d lG(/C�/S Project Location: County '
3•% U G N ,':) 1411r' 0 Street Addres/ S to Road/ Lot #(s) -
{ ` State A/C. 'Zip? 74 I L- Z
O S 7 I Subdivision
-�
zed Agent
Xf1��iN jC City i. ZIP❑ Cw PTA ElES ElPTS Phone# ( River BasinElOEA CI HHF IH ❑ UBA ❑ N/A
Adj. Wtr. Body
❑ PWS:
yes , no) PNA yes no
Closest Maj. Wtr. Body
' if rojei '' F
c�t/� Activity �.�`� (� j l,r car A-, �� /�� (� '' �' �( ,� ,!%d
(Scale: ��
ock) lengthb AI
'latform(s)
g Platform(s)
pier(s) 3 X
uum
ad/ Riprap length
vg distance \offshore
iax distance offikore
channel
ubic yards
ine Length
Drium:
Attached:
ding permit may be required by:
a Local Planning jurisdiction)
❑ See note on back regarding River Basin

NC Division of Coastal Mgt Habitat lmpaot COMPuter Sheet
` � v �S
Applicant: NO
Date:
Describe belo e HABITAT dist Pances 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 FIN
(Applied for. (Anticipated final (Applied for. dint
DISTURB TYPE Disturbance total disturbance. Disturbance dish
total includes Exc
Habitat Name Choose One includes any Excludes any
anticipated restoration any anticipated rest
restoration or ternrestoration or and/or temp
I
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 ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Applying for Permit: &I'1 4' /' f j/
Mailing address:
Phone Number:
I certify that I have authorized
—' Agent / Contractor
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of A�
at my property located at
in 6.4,11 Y/ County.
This certification is valid through
Date
(Property Owner Information)
Signat re
Print or Type Name
Title

CERTIFIED MAIL - RETURN RECEIPT REQUESTED4- t, ;, a
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAIVER FORM
Name of Property Owner:
Address of Property: // 7 Y k-, e r e ` z 0 f /n p sa-)
(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.
_ 4;4 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 (DCM) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext,
Wilmington, NC, 28405-3845. DCM representatives can also be contacted at [phone]. No response is
considered the same as no objection if you 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\I v I do not wish to waive the 15' setback requirement.
(Property Owner Information)
� Sign ure
Print or Type Name
_37C1
Mailing Address
(Adj ent P o�p er Information)
Sign ure
-baV
Print or Type Name
Mailing Address

CERTIFIED MAIL - RETURN RECEIPT REQUESTED 4_ / e )-� C
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
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 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 (DCM) in
writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext.,
Wilmington, NC, 28405-3845. DCM representatives can also be contactr_-d at [phone]. No response is
considered the same as no objection if you 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)
Signature/
Print or Type Name
(Adjacent Frooefty!Owner Information
Signature
Print or Type Name
3 0
(lr a i 'I'd I Ico iW (,t ib,i
Mailing Address T—
Mailing Address

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