69188D - Grimsley

*AMA / DREDGE & FILL
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3NERAL PERMIT
Previous permit #
?k" ❑Modification ❑Complete Reissue ❑Partial Reissue
Date previous permit issued
wized by the State of North Carolina, Department of Environment and Natural Resources
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
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❑Rules attached.
it Name V Wl t
Project Location:
County����/yts V 'C
Street Address/ State
Road/ Lot #(s)
State ZIP
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I E-Mail
Subdivision
zed agent t� (N>^ S ^ C Kwdt
City
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�� ZIP_
�'CW W PT ❑ ES ❑ PTS M �1
+Phone (� ��)
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t l' t ( V 1 D River Basin
❑ OEA ❑ HHF ❑ IH ❑ USA ❑ N/A
Adj. Wtr. Body
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(GY1V1Q(I LY (601� �iaa I
❑ PWS:
yes / 0 PNA ye •-
Closest Maj. Wtr.
Body kA 041,61
f Project/ Activity
)ck) length W
latform(s)
Platform(s)
)ier(s)
mgth
amber
W Riprap length
g distance offshor
ax distance offsh e
hannel
bic yards
ng permit may be required by: K;10 �t 61 L ❑ See note on back regarding River Basin r
Local Planning lurisdiction) 1

Pat McCrory
Governor
AkFA - -
an
North Carolina Department of Environment and Natural Resources
N.C. Division of Coastal Management
Joint E. Skvai
Secrets
AGENT AUTHORIZATION FORM
Date:
Name of Property Owner Applying for Permit: Name of Authorized Agent for this project:
Owner's Mailing Address:
t �r
Q
Email: �'01 Y:�D%
Phone 24
Agent's Mailing Address:
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5yoa1rVt� �K4(o2
Email: dn[ s 2,5 A rA yha co
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Phone Lq9J T4 3-11911--____
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
for, and obtaining ail ,AMA Perm ts necessary to install or construct the following (activity):
For my property located at
This certification is valid 1 year from (date) �5—, ^/--

I�G�i,2 U r AJ
CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner
Address of Property
Agent's Nance a i rr,
e .-
Agent's phone it
I hereby certify that I own property ad)acent to the above reference property. The individus
applying for this permit has described to me as shown on the attached drawing the developmen
they are proposing A qes rit)Uonor dra% mno with dimensions must be provided with this letter
Y,,�++►�� t have no objections to this proposal. I havc objections to this ptoposanl.
.0
N you have objections to what is being proposed, you must nobly the Wtision of Coastal Managat"OM MM 1
writing within 10 days of rocoipt of this notice. Correspondence should be mailed to 127 Cardinal Vdit Exi
Wilmington, NC, 28405-3845. DCM reprosonratives can also be contacted a: [phone]. No response i
considered the same as no objection it you have boon notified by Certified Mail
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
bads 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) �1 I
f-tIe Qre- rV((a1 W1D`
•�.l I do wish to waive the 15' setback requirement baU�S Sa
�yQf 1 do not wish to waive the ? 5' setback requirement s, v S�(/ry
(Propertyy,,ntpsotati j
J Signawre
(A "acent Property Owner Information)
, .
SUxnUt ure

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DATE & TIME STATUS OF ITEM
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LOCATION
February 8, 2017, 11:27 am Delivered, Left with BOLIVIA, NC 28422
Individual
Your item was delivered to an individual at the address at 11:27 am on February 8, 2017 in
nni nnn AV` OQAO7

ox.JtAurAi
CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAIVER FORM
Name of Property Owner
Address of Property /Dg l`F is KD/'r� s J''
(Lot or Street a stfeei or Koac, Guy Q
Agent's Name ss I-lo laS Address
Agent's phone # `1/0— yY 3-
6
I hereby Certify that I own property adjacent to the above referee property. The individu
applying for this permit has described to me as shown on the attached drwAng the developme
they are proposing A descnotion or drawing with dimensions must be provided with this fetter
�,,,��►(� ' �l`> l havc no objections to this prulx)sal. I have objections to this proposal.
N haw objections to -fiat Is ed
I— , y1ou must Illy the Oivislon o/ CoasbN Atanagemertt
wrfWV wiWn 10 days of receipt of this notice. Correspondence should be am~ to 127 Cardinal Drlvo Ex
Wilmington, NC, 28405-3M. DCY reprwentadves can also be contacted at [phone]. No response
considered dw same as no objecdwr ft you have been nodffed by Cer ied Mall.
WAVER SECTION
I understand that a per. dock. moony pilings, breakwater, boathouse, lift, or groin must be set
back a minimum distance of 15' from my area of ripanan access unless waived by me. (If you
wish to waive the setback, you must initial the appropriate blank below)
1 do Nash to waive the 15' setback requirement
we arse.. ,vaf w,1' -I
se -� baz�6 sa P
I do not wish to waive the 15' setback requirement.�>J
(Property Own go�ti j j
aAae,f -
tlj
Signature
(Adjacent Property Owner Information)
Signature
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