67214D - Register

New ❑Modification ❑Complete Reissue El Partial Reissue
Date previous permit issued
zed by the State of North Carolina, Department of Environment and Natural Resources �..� j j • w Z o o f
oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC Rules attached.
Name -M f� (546 Project Location: County ( V ` n ✓J
?U �i Street Address/ State Road/ Lot #(s)
t S'�c tiU State /�C-ZIP (W �i r.�i 'J tAJ
�t
ed Agent
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ N/A
❑ PWS:
yes I- PNA yes / no
r Project/ Activi
ck) length
atform(s)
;ngth \
amber
id/ �iprap length
g distance offshore
ax distance offshore
channel J �'
,bic yards
mp _
3ulldozing
Subdivision
city � �; _,..�,� �• � .� ziP_
Phone # (�""""` River Basin
Adj. Wtr. Body f ll/I 2Y -l'l (natAt
Closest Maj. Wtr. Body
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(Scale:

IBC Division Of Goa tal .i t. I�Iabitat Irnpaot- coMputer Sheet
Applicant: Kp/h►
Date:
Describe belowthe HABITAT disturbances for the application.
All values should match the name, and units of measurement found in. your Habitat code sheet.
S Ft FINAL Sri Ft. TOTAL Feet M
DISTURB TYPE
Habitat Name
Choose One
D liJ
Dredge El
Fill
Both ❑
Oth
Dredge
Fill El
. El
Oth(
Dredge []
Fill
Both Cl
Oth(
Dredge ❑
Fill ❑
Both El
Othi
Dredge ❑
Fill El
Both ❑
Othi
Dredge. ❑.
Fill []
. Both ❑
Oth,
Dredge El
Fill ❑
Both FT
Oth
TOT�.L q.
(Applied for.
(Anticipated final
(Applied for.
(An
Disturbance.total
disturbance.
Disturbance
dill
includes any
Excludes any
total includes .
EX
anticipated
restoration
arestoraant'tiontor
restoration or
and/or temp
ten
ternimpacts)
lm act amount)
temp iin acts
am
er ❑
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:ram 2. ��: � • I'� . .

I, Jason
1: Register's Septic Tank Pumping <[e-mail]>
Tuesday, September 13, 2016 10:20 AM
Dail, Jason
ect: 450 Chadwick Acres Rd., Sneads Ferry
n Register, authorize Brandon Grimes to act as my agent.
i ks

CERTIFIED MAiL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or Street #,
Agent's Name #:
Agent's phone #:
,
or Road, City & County)
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 mustnotify the Division of Coastal Management
(DCM) In writing within 10 days of receipt of this notice. Contact information for DCM offices Is
available at http:lAvww.nccoastalmanagement.nebweb/cmistaK-iisttnd or by calling 1-888-4RCOAST.
No response is considered the same as no objection If you have been notified by Certified Mall.
WAIVER SECTION
i understand that a pier, dock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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
A- I do not wish to waive the 15' setback. requirement.
(Property 4vner lnforma o) (Riparian Property Owner information)
l�
Signature Signature
Print or Type Name Print or Type Name
AAnilh dHrfr.Q*c Mallina Address

r '
Y
CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Q i ;• ,;; •� - r /- -
Address
of Property -
(Lot or Street #, Street or Road, City & Ccunrr)
Agent's Name #: Mailing Address:
Agent's phone #.
.••rra�rar�ir ..��
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. Contact Information for DCM offices is
available at tt :lAvww.nccoastaimana ement.net/web/cm/staff-llsUn orbycallingt-aa&4RCoAsT.
No res onse 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, boat ramp, breakwater, boathouse, or lift 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,
(P operty ner I' a a j 1parian P O ner Information
Signature uture
Print or Type Name Pri or pe Nam
.Mailing Address Mailing Address

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