69370D - Davis

o,.
AMA / Q DREDGE & FILL 13) ' A B
aENERAL PERMIT �T Previous permit #
1�lew ❑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 15A NCACCEZ
❑ Rules attached.
t Name (/l Project Location: County K r m'� I, 4
JY'( �n <- Street Address/ State Road/ Lot #(s)
State zip a�qk 0 U t'0 ra
( L -Mail " "— Subdivision ------
ed Agent (A c Y ear' City ' �� ZIP 1
❑ CW yew A ❑ ES El"S hon
( 1 ) I River Basin -iA
❑ OEA /❑`HHF n 1H ❑ UBA ❑ N/A
Adj. Wtr. Body a /1Gl (nab
❑ PINS:
yes / PNA yes / �1 Closest Maj. Wtr. Body .� 1 A / I A 1
' Project/ Activity
:k) length
itform(s) %
Platform(s)
ngth
-nber
i/ Riprap length
distance offshore
x distance offsho
cannel
sic yards
np
se/ BXatlift
e Length
not sure yes
ium: n/a yes o !
y T
es o I
kttached: yes no [(
ng permit may be required by: A/'�� [ J(Q A V1 'e 6eikC ll ❑ See note on back regarding River Basin r

opt
� � 3jh� e HOC
/? /

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
cCrory Braxton C. Davis John E. Skvarla, III
;rnor Director Secretary
AGENT AUTHORIZATION FORM
Date:
of Property Owner Applying for Permit: Name of uthorllze"ent for this project:
Liz
Mailing Address:
Number(` f3 - `fit© - -)4Ci5
Agent's Mailing Address:
-D 'fie ),��
�� // Q AZ
V5--`I"
Phone Number (1/y �/�? % 2 Z
that I have authorized the agent listed above to act on my behalf, for the purpose of applying
obtaining all CAMA Permits necessary to install or construct the following (activity):
t
A- J
property located a
rtificatio is valid thru (date)
i r
Property Owner Signature
Date

DIVISION OF COASTAL MANAGEMENT
Name of Individual Applying For Permit:
Address of Property:
P rtY:
(Lot or Street #, Street or Road)
(City and County)
hereby certify tat own property aTJacent to the above --referenced property. The iE
applying for this permit has described tome as shown on the attached drawing the developme,
are proposing. A description or drawing, with dimensions, should be provided with this let
I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of C
Management, 127 'Cardinal Drive Extension, Wilmin;ton, INC 28405 or call 910-79E
within 10 daysof receipt of this notice. No response is considered the same as no objec
you have been notified by Certified Mail.
-WAIVER SECTION
understand that a pier, dock, mooring pilings, breakwzter, boat house or boat lift muse
bck a minimum distance of 15' from my area of riparian access - unless waived by me.
wish to waive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement.
XI do not wish to waive the 15' setback requirement.
lC h Sii Name Date
A/, .. - ,rR Ado,,,,fA
.,.NOW-ME-�.

DIVISION OF COASTAL MANAGEMINT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORK:
Name of Individual Applying For Permit:. L i
Address of Property:_
(Lot or Street #, Street or Road)
(City and County)
mere y certt that I own property a acent to the a o�ve-reI`emnce property. The indi
applying for this permit has described tome as shown on the attached drawing the developme
are proposing. A description or drawing, with dimensions, should be provided with this lei
I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of C
Management, 127 'Cardinal Drive Extension, Wilmington, INC 23405 or call 910-79,
within 10 days -of receipt of this notice. No response is considered the same as no obje(
you have been notified by Certified Mail.
WAIVER: SECTION
understand that a pier, dock, mooring pilings, breakwzter, boat house or boat lift mus
bck a minimum distance of 15' from my area of riparian access - unless waived by me.
wish to waive the setback, you must initial the appropriate blank below.)
/I I Y-WAY
vName
r do wish to waive the 15' setback requirement.
I do not wish to waive the 1 5' setback requirement.
Date

■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
IIIII III IIIII III I IIIIIII I IIIII
9590 9402 2021 6123 2951 06
A. Signatur
El Agent
X ❑ Addressee
B. ec Ived by (Printed Name C. Date of Delivery
-tt �i5 �j 111-1�1t? /4� e YZ 7 % D
D. ds delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3. Service Type
❑ Priority Mail Express(D
❑ Adult Signature
❑ Registered MailT"
❑ Adult Signature Restricted Delivery
❑ Registered Mail Restricted
❑ Certified Mail@
Delivery
❑ Certified Mail Restricted Delivery
❑ Return Receipt for
❑ Collect on Delivery
Merchandise
2 rrransfPr from service label) ElCollect on Delivery Restricted Delivery Signature Confirmation"'
n I-- "email ❑ Signature Confirmation
7 01, 6 0600 0000 5522 3472 Restricted Delivery Restricted Delivery
PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Return Receipt
PostalTI
Postal Service"'
CERTIFIED oRECEIPT o .
CERTIFIED
..ECEIPT
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nly
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