67198D - Walters

CAMA / ❑ DREDGE & FILL 11�;�<3//(, `�L— ;TO s`��9� A B
GENERAL PERMIT Previous permit#
4.4ew ❑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 ❑ Rules attached.
Name ' O'm 6y-n y_ Project Location: County ���Y RR K
3 U Street Addre�sss/' State Road/ Lot #(s)
State NC ZIP
(NDAPO$' 91ai E-Mail Q5�-�nCl�"Sa�aor-�Uv�� Subdivision
3dAgent 306\ wfI City bj(e(10 TS\-e 6ffAt ZIP
❑ CW ) EW PTA ❑ ES ❑ PITS Phone # ( ) River Basin u y�
❑ OEA ❑ HHF IH ❑ UBA ❑ N/A Adj. Wtr. Body at n
❑ PWS:
yes /'no PNA es /" Closest Maj. Wtr. Body
Project/ Activity L{
:k) length S t' t '
tform(s) 16--
3latform(s)
igth
nber
I/ Riprap length
distance offshore
K distance offshore
annel !/
iic yards
ip
W O3( atl
Length s
not sure yes no
um: n/a yes
yes
atached: yes g94...
ig permit may be required by: T(%iVA J Vt
_ocal Planning Jurisdiction) ,
al k 1�l
(Scale: C
h J'S�c F)(60 El See note on back regarding River Basin n

kC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: V'v G(1 Permit #:
Date: l yl 1/1 Z ;v , .
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
or
im acts}
FINAL Sq. Ft,
(Antidpated#inal
disturbance.
Excludesany
restoration
and(or temp
impact amount
TOTAL FeeTdisturbance.
(Applied for..Anticipated
Disturbance
tots(includesxcludes
any anticipateestorationand/orrestoration
restoration ormp
temp impacts)mount
INAL Feet
final
any
impact.
1tem
O"A
Dredge ❑ Fill ❑ Both ❑ Other
2
I Z
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge.❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge E] Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other 171
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
late Received 1 11/10/2016
heck From (Name) FYJYNM LLC
lame of Permit Holder Clayburn Walters
Iendor First Bank
.heck Number 112
heck amount $200.00
lultiple Permits No
lajor/Minor
ermit Number/Comments GP 67198D
receipt or Refund/Reallocated SF/2840D

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date ! � / 6
Name of Property Owner Applying for Permit: 1
v— Me, L L C
Mailing Address:
116-F35' 0 13� �E
Fa.�1 r- ►-h o Vet l a c 0?,
I certify that I have authorized (agent) IN 4+ T/o to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) R �p �aLC- <- E' x S' t ti n
at (my property located at) 9`� in c9 ►-� ry O,l �%
This certification is valid thru (date)
-- / -- / 6
Owner Signature
Date

US MAIL
CERTIFIED MAIL — RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner: 96 m O ti re ���' e_ L C- ` b wr'''�
Address of Property: D vx V` ® e- ��[ (-
.�J y C
q q �y (Lot or Street 9, Street or/Road, City & County)
Applicant's phone #t: / 10 ` D / / D1 Mailing Address: E'
I hereby certify that I own property adjacent to the above referenced property. The individual applying for this pern
has described to me as shown on the attached drawing the development they are proposing. A description of drawir
with dimensions, must be provided with this letter.
Xo�— 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 E:
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, or lift must be set back a minimum distance
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 1S' set back requirement.
I do not wish to waive the 15' set back requirement.
(Property Owner Information)
Signa j o� ► +-C r5
(L' I OL
q3' n rr0LC
Print or Type Name
Mailing Address 9
(Riparian Property Owner Information)
Signature
a tr r-q L I'3 . L. I e, c 7 .
Print or Type liame CC/ J mo r-► ro e-- ;
Mailing Address
lV I- 1 -N--, on U n n

JS MAIL
CERTIFIED MAIL - RETU%N RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
ame of Property Owner: g`5' M 0✓►r0 C Sf ' LLB
ddress of Property
C laiy b
� 6— (11 0 VAro ,Q- 5�-- 0,
(Lot or Street #, Street or Road, City & County)
agVI, 7 Ory
pplicant's phone #l: "/ '� OF ~ ` 76 Mailing Address: )(5- 8,�5 6-
hereby certify that I own property adjacent to the above referenced property. The individual applying for this permi
is described to me as shown on the attached drawing the development they are proposing. A description of drawin
ith dimensions, must be provided with this letter.
I have no objections to this proposal. I have objections to this proposal.
f you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM)
i writing within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Eat
Vilmington, NC 28405-3845. DCM representatives can also be contacted at [phone]. No response is
onsidered the same as no obiection if you have been notified by Certified Mail.
WAIVER SECTION
understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be set back a minimum distance o
5' from my area of riparian access unless waived by me. (If you wish to waive the setback, you must initial the
ppropriate blank below.)
I do wish to waive the 15' set back requirement.
I do not wish to waive the 15' set back requirement.
Property Owner Information)
>ignat re
Tint or Type Name
Mailing Address
I''- , - -- ---.4. nIn U/)
(Riparian Property
yOwner I, ormation)
Signature
Print or Type Name
Mailing Address
/37 T a

HAND DELIVER
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOOPJNG PILINGSBOATLIFTBOATHOUSE �-e S
61a-`� bcLrh
I hereby certify that I own property adjacent to '13r% o ►1 r D 's
(Name of Property Owner)
property located at C% b o ✓t r U e— 5 d J 0,
(Lot, Block, Road, etc.)
on , in 00—e— tct__v\ :J�* I e ccc-4 , N.C.
(Waterbody) (Town and/or County)
%C — c5 w D
Applicant's hone W. (ob `0/ % O 1 Mailing Address: /. 5 3 `5
c) Air 5 lye
Fle has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (I Y) 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 not wish to waive
I do wish to waive that setback requirement.
------ ------------------------------------------------------------------------------------------------------
DFSCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPM) NT:
(To be filled in by individual proposing development)
v CA l .1 e , 1 D n 0.
(Information for Property Owner Applying
for Permit)
oek
Mailing Address
------------------------------------------------------�
(Riparian Property, Owner Information)
Signature
f}ss4-. • -to •

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53101121* NSF6/30/2016
303623009
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is a LEGAL COPY MA
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_ FYJYNM LT,C 1
i t the same way o
PO -BOX 1532
would use the o r-4
SHALLOTTE NC_28459-1532 531 DATE
ginaI check.
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IN REASON -A
U F F I C I E N T Mr_1
Pay totha
order of H'L /4
FUNDS
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1
Payment Proccessing Confirmation
Date Received 12/15/2016
Check From (Name) John West
Name of Permit Holder Clayburn Walters
Vendor Postal Money Order
Check Number 24031116652
Check amount $200.00
Multiple Permits No
Major/Minor
Permit Number/Comments 67198D
Receipt or Refund/Reallocated SF/3480D