67988D - DJM

CAMA /DREDGE & FILL
3ENERAL PERMIT
-New Modification El Complete Reissue ❑Partial Reissue
1988 A B
Previous permit #
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 + ? Ito Q t . 12-00
❑' Rufus attached.
t Name �jj f Y1� — N—G I L LC, C/O 1>-NI GL, �7 (Orr 16ject Location: County H-P,1\40 uex.
I� J1 I �1 A *-k F4 • Street Address/ State Road/ Lot #(s)
I L V\A . State Nc_ zip;? r,kQr1`
(I (0) Uo ' 45'T + E-Mail
ed Agent M A R K C-cz & C;Ni t
❑ C:W/ ¢SEW VPTA I*S ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ URA ❑ N/A
❑ PWS:
Subdivision
CityVY IL - IA
Phone #
ZIP Z K4 I
River Basin
Adj. Wtr. Body A I UV VJ
yes- no PNA yes no
Closest Maj. vvtr. Body1111 I L'ID
' Project/ Activity (-or Iazlel k U I k IN¢--,J 5 &,ew CJY 1-4 C4— Ne,_J n /f -mil
(Scale:
No
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1
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:clistance offshore
x distance offshore
annel
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rig permit may be required by: t4` 4ti ow -- C—b • ❑ See note on back regarding River Basin r
1 n 1 pin—i.,.,

NC DIVISIOn 91r �eQ �<Cdl'.1�1b�f6a 9AaAo aeaua xeealaw
- — -
plicant
l
te: L ^3 ^ J7
scribe below the HABITAT disturbances for the application.
values should match the'name,.and'units. of measure►�ent
found in. your Habitat code sheet.
TOTAL Sq. Ft.
for.
FINAL Sq, Ft.
(Anticipated final
TOTAL Feet
(Applied for.
FINAL Feet
(Anticipated final
DISTURB TYPE
(Applied
Disturbance total
disturbance.
Excludes any
Disturbance
total includes .
disturbance.
EXdUdes any
bltat Name
Choose One
includes any'
anticipated
restoration
any antiei�ated
or
restoration and/c
temp irnPact' `
restoration or
tamp impacts)—
and/or temp
impact amount)
restoration
teMP iiti acts
amount
Dredge ❑ Fill ❑ Both ❑ Other
4
�
Dredge [IFill Both ❑ Other
Dredge E] Fill ❑ : Both .❑ Other []
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill El Both ❑ Other L7
Dredge. []. Fill ❑ . Both ❑ Other ❑
_
Dredge ❑ Fill ❑ Bofh ❑ Other E]

Letter of agent
I j f 'N � �.-L . have retained Mark Clements UI3A, Clements
Marine Construction Inc, to make application for any and all permits needed to start
construction on the work requested for our property or properties.
By allowing Mr. Clements to make such applications I do understand that this will in no
way relieve me of any obligations to perform all work according to the building codes of
North Carolina, CAMA, DWQ or any other state and or county ordinances.
-n
Print nam
`L- M
Signatur
61) 1) - zho - y date 10 31�
Contact information

Payment Proccessing Confirmation
Date Received 1 1/3/2017
#heck From (Name) Clements Marine Construction INC
Name of Permit Holder DJM-NC, LLC c/o Daniel Smith
Vendor First Citizens Bank
Check Number 4298
Check amount $1,200.00
Multiple Permits No
Major/Minor
Permit Number/Comments GP 67988D (fee is $600)
Receipt or Refund/Reallocated JD3529D

mftacent rip utter for UID4 GE Ir,.Ipeg
'12=iM 12:0
-A �;- tit iflPARIAN PRC�PERTY OWNER STATE MEN T
Name al Pfooeft.,
7C lt Ivc 71
iAcw-s, -Pt ti:oc, woac e-..-
tv
DESCRIP'NON ANDOOR C*AWI
dp,*j"m—,f —t l'J. 'rac .-N- O'u

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to VJ fY1- r� I✓ (,(,C- I
n 1 (Name of Property Owner
property located at AX P 6 le, L JJ L • tic q
` (Address, ot, Block, Road, etc.)
on /4TGhJ , in 1�@(n� A%Ylnt/C( Lo N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loYolk—
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
Lo f%lGd/i//
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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.
_00— 1 do not wish to waive the 15' setback requirement.
(Property Owner Information) (Adjacent Property Owner Information)
oL,l
Signature A6ature *.
Print or Type Na►J�e Print or Type Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to DJ f N— t'� 's
property located at
on
(Address, Lot, Block, Road, etc.)
A r-. , in _Met%) i aYtnvet' Lo , N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above
loc io' �
/ )1-,� 1 have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
�ee
WAIVER SECTION
I understand that a pier, dock, mooring pilings, boat ramp, 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.
fx' I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Sigtauh e
Print or Type Name
(Adjacent Property Owner Information)
Print or Type Name

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CAMA /'DREDGE & FILL A B
��
w�p
'ENERAL PERMIT Previous permit #
New ❑Modification ❑Complete Reissue ❑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 I SA NCAC
❑ Rules attached.
t Name L;`fsYE D Nt u Project Location: County �
r
L1AA State " C_- ZIP4' ('"~
Street Address/ State Road/ Lot #(s)
O E-Mail S division_
ed Agent.� (`� I ._.� ZIP �.�Q• t
❑ CW EW PTA S ❑ PTS 7t�►� Phone #
�. !1E? ¢� r ` \ �(� ("�"""� River Basin
❑ PWS: ❑ HHF ❑ IH ❑ URA ❑ N/A t`�` Rdj. Wtr. Body; lJ� to
e"s / no PNA es o ` ``��Closest Maj. Wtr. Body
V y / 7 fh\
Project/ Activity
:k) lengthy g
t
tform(s)
'latform(s)
igth
fiber
/ Riprap length - _.
distance offshore,
c distance offshore
is yards
1'*d jng
Length
:tached:
g permit may be required by: C-6
❑ See note on back regarding River Basin rr
Kcal Planning Jurisdiction)