69173D - Farmer

i,CAMA / Cl DREDGE & FILL A B
jENERAL PERMIT Previous permit#
Flew L_iModification ❑Complete Reissue LPartial Reissue Date previous permit issued
-ized by the State of North Carolina, Department of Environment and Natural Resources R _) j
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC (� / I� , SJ�U 0
❑ Rules attached
Name / Y G\ [G1 Y 64Y
ap 1S (.
M SStated ZIP `1110 5
0-10— 1-7 1 1N HI E-Ma'I
ad Agent
❑ CW XW A ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes / q6 j PNA yes /
Project Location: County 0',1 K
Street Address/ State Road/ Lot #(s)
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Subdivision "
City i i44A ttl (V ZIP ,
hAlone LS 10 River Basin Lvw
Adj. Wtr. Body 6�k l�i�,,/� (nat /a
? j f Closest Maj. Wtr. Body ww/
Project/ Activity j ' n ��/�� GLi 1 i tq- CA �A C! r-( I CkV-► jj►^{_
JQ kh
(Scale:
:k) length
ltform(s)
Platform(s)
igth
nber
I/ Riprap length
distance offs
K distance o sh
annel /
ip
;e/ B atli
Length
um: n/a yes
yes o
,ttached: es no
ig permit may be required by: I OAM 6 &C &&"t''
.ocal Planning jurisdiction) /j /7 , r �� I

VC Division of Coastal Mgt. Habitat Impact Computer Sleet
kpplicant: f ' `� �� �,.eir Permit #: D
)ate:
)escribe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
Fund in your Habitat code sheet.
labitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated final
disturbance.
Excludes any
restoration and/or
temp impact
amount
U�
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 ❑
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 171 Other ❑

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ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
1 hereby certify that I own property adjacent to G ����'� s
— V �_ IN,,ano of Property Owner)
property located at I 17 + �lGU�r;�� 5 «��� —
(Address, Lot, BIgcRo c )
on , in H01- l flel/ P �MH N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above location.
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)
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to waiv
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.
(Property qwner t rmation)
L
Sign rlD�
P ' t or Typ Nam , `c
(Adjacent Property Owner Information)
igna
Print or Type Name ``
7: ; .v �.? r', % 7LH "7`
Unilinn drlrirnce

sommo� ■ Complete items 1, 2, and I
• 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 t E-14 C' �` `v
G� �n/ —CL'� VIV
n,rc�(G�Er 1
IIIIII'�II�"II�IIIIII���III�II
III'III'I III'
9590 9402 1587 5362 8815 49
2 GrfirlaW'. ?.,��,_,., 0000 0043
7016 214L1
PS Form 3811, July 2015 PSN 7530-02-000-9M
N;. i9neture ' 0 Agent
X ❑Addressee
' =
B, deceived by
Printed Name) C. Date of Delivery
D. Is delivery address different from item 17 ❑Yes
If YES, enter delivery address below: O No
3. Service Type
p Adult Signature
p Restricted Delivery
Adult Signature
Cl Certified MailCt
0 Certified Mail Restricted Delivery
0 Collect on Delivery Restrcted Delivery
CI Collect on Delivery
ul
6 4 9 ? ril Restricted Delivery —
❑ priority Mal Expresso
0 Registered Mail-
❑ Registered Mail Restricted
Delivery
❑ Retum Receipt for
Merchandise
❑ Signature Con
firmationTM
❑ Signature con4rmalion
Restricted Delivery
Domestic Return Receipt

March 22, 2017
Mr. Semprevivo,
I am planning to build a boat lift at my beach house at 117 Fayetteville Street, Holden Beach. As you are
an adjacent property owner, I am sending you a notification/waiver form about the project. In
reviewing the map attached to the form, you will see that the boat lift will be located between the dock
for our house and the one for 115 Fayetteville Street so it should have no impact on your ability to
install a boat lift in the future.
If you have any questions, feel free to call me at 980-297-1447.
Thank you.

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: _A#(K
Address of Property: FAYF /1�0�5 - H0�8�r''r� �C pl���/5�(%i�
(Lot or Street #, Street or Road, City & County)
Agent's Name #:
Agent's phone #:
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 p posing. 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. Correspondence should be mailed to 127 Cardinal Drive Ext.,
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, 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.
Vz I do not wish to waive the 15' setback requirement.
(P7d;
ner Inf rmation)
Signature
Print or Type Name
300 gal/o/c/ wcbvs IPA -
Mailing Address
(A - cent Property Owner Information)
Signature
Print or Type Name
211 Z RX Cttc 0g.
Mailing Address

March 22, 2017
Red: Band-1
Green: Band-2

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