69326D - Ford

' dAMA / . DREDGE & FILL
3'ENERAL PERMIT Previous permit# A B
New 'Modification ❑Complete Reissue Partial Reissue Date previous permit issued
rized 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 0 �. (Z Q ()
Rules attached.
t Name �_o � �v-I � Project Location: County }�1 (.�-
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❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A Adj. Wtr. Body nat i
❑ PWS:
yes no PNA yes Ono Closest Maj. Wtr. Body
' Project/ Activity
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ngth
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x distance offshore
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1

Steve and Lisa Grubb
707 Flat Swamp Lake Rd
Denton NC 21239
336-209-3448 (Lisa)
i oaa ana 5urte Ford
4910 Gaynor Rd.
Charlotte, NC. 28211
704-649-4117
1
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&LIT �._ WWI
VENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson Dee Freeman
Governor Director
Secretary
AGENT AUTHORIZATION FORM
Date: July 12. 2017
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project.
Todd Ford
Owner's Mailing Address:
4910 Gaynor Rd
Charlotte. NC 28211
Phone Number(_ 70, 1649-4117
Will Richardson
Agent's Mailing Address-
3235 Seacrest Ave. SW
Supply NC 28462
Phone Number( 910) 367-0335
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for and obtaining all CAMA Permits necessary to install or construct the following (activity):
Boatlift Installation
(my property located) at 131 Raleigh St Holden Beach, NC 28462
Ttzi: certifications valid thru (date) January 12, 2018
I
{1
Property Owner Signature Date

.An^,J , lk►,e0J
RTIFIED MAIL — RETURN RECEIPT RE LESTED
DIVISION OF CO_AST_AI, N.NNAGEIYIENT
ADJACENT RIPA.RI.AN PROPERTY OW ER STAM,fE11iT
I hereby certify that I ONvn property adjacent to Todd Ford
`s
Property located at 131 Raleigh St (Name of Property Owner)
on Canal (Lot, Block Road etc.) '
in P� lden Beach
(Waterbodp} N.C.
Applicant's phone #: [phone] (Town and/or County)
-MailingAddress: 4910 Gaynor Rd
Charlotte, NC 28211
He/She has described to me as shown below the development he/she is proposing at that location,
and I have no objections to the proposal_
DESCRIPTION AND/OR DRANVING OF PROPOSED DEVELOPMENT: (IndividualPraposino' development mustfillIn d6scriPtion below or attach a site drawing)
Installation of boatlift. Please see the attached drawing.
If you have objections to what is being proposed, you must notify the Division of Coastai Management (D 1 in writin
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext, W�ngton, NC g
DCM representatives can also be contacted at [phone].
Na res 2onse is considered the same as no ob'ectlon if You have been notified by Certified Mail
(Property Owner Information)
it n PrRerty Owner Information)
Authorized Agent / �' ' ' 1
Signature �� �It
Signature .
Will Richardson
Print or Type Name
3235 Seacrest Ave SW
Mailing Address
Supply NC 28462
City / State / Zip
Richard or Ann McCain
Print or Type Name
Mailing Address
Fie 5
City / State / Zin

r , ,__
' ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORIIYG PILINGS/BOATLIFTBOAT HOUSE)
I hereby certify that I own property adjacent to Todd Ford
(Name of Property Owner)
property located at 131 R
on Canal
11
St
.(Lot, Block, Road, etc.)
_, in Holden Beach , N.C,
(Waterbody) (Town and/or County)
Applicant's phone #- [phone] Mailing Address- 4910 Gaynor Rd
Charlotte, NC 28211
He has described to me, as shown below, the development be 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 (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 not wish to waive
iitial here:. I do wish to waive that setback requirement;
DESCRIPTrON A-N-D;OR DRAWING. OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
Installation of a boatlift. See attached drawing.
(Information for .Property Owner Applying {Riparian Property-�
for Permit) owner Information) -
Searest Ave, SW �` #
Maailiia ng Adddress L -
s
Supply, NC 28462 Sattxre
Gam,/St telZip — Lisa or Steve Grubb
[phone] Vint ar Type Name
Telephone?v,m,t3.3u

9 W /
r
r
ADJACENT RIPARIAN PROPERTY OWNER STATM
(TOR A PIERImooRING PILINGS/B0ATLIPTBOAT HOUSE
I hereby terrify that I own property adjacent to
Todd Ford
(N. ame of Property Owner)
property located at_ 131 Raleigh St
(Lot, Block, Road, etc.)
on — Canal _ in _ Holden Beach _ , N.C.
(Waterbody) (Town and/or County)
Applicant's phone#: [phone] Mailing Address: 4910 Gaynor Rd
Charlotte, NC 28211
He bas 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 (15� from my area of riparian access unless
waived by me. (If you wish to waive the setback, you must initial the appropriate bl nk
below.)
I do not wish to Nvaive
iitial here• . _ I do wish to waive that setback requirement
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be fdled in by individual proposing development)
Installation of a boatlift See attached drawng.
(information for Prop, Owner Applying
for Permit)
3235 Seacrest Ave, SW
Address
Supply, NC 28462
City
910 367-0335
Takplwna u�,----------____---
_-- -_
(Riparian Property Owner Information)
S
Lisa or Steve Grubb
Print or N
__3 3� lmcl - su k.Lcr

CERMUD litA1T.--ice' W RECEIPT REQUESTED
DIVISIOY OF COASTAL MA_ AGEWNT
ADJACEZN-T RIPARIAN PROPERTX OVYER STATEIN ENT
I hereby certify that I own Property adjacent to Todd Ford
's
ro p periy located at 131 Raleigh St (Name of Property Owner)
(Lot, Block Road etc.))
on Canal In F�olden BeacF�
(Waterbody) N.C.
Applicant's phone #: [phone] MailingAdwnan� 49 0 or Ga ty) Rd
Charlotte, NC 28211
HeiShe has described to me as shown below the development he/she is proposing at that location,
and I have no objections to the proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(7ndi>ridual proposing development musf fry in dZscription below or attach a site drawing)
Installation of boatlift. Please see the attached drawing.
If you have objections to what is being proposed, you must notify the Division of Coastal Management (D
within 10 days of receipt of this notice. Correspondence should be mailed to 127 Cardinal Drive Ext. waminngton NC
DCM representatives can also be contacted at (910) 796-77,15.
No res nonse is considered the same as no ohiecfion if ou have been notified by Certified Mail
(Property Owner Information)
Prpyerty Owner Information)
Authorized Agent
Signature
Signature
Will Richardson
Print or Type Name
3235 Seacrest Ave SW
Mailing Address
Richard or Ann McCain
Print or Type Name
Z G 17 (o A( /t,t*LJ- f) fi__
Mailing Address
Suppiv NC 28462
City / State / 7.in
A' 06i s 'Vc- Z g iv �;—

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