68501D - Hewlett

k�AMA`/ ` DREDGE & FILL
3ENERAL PERMIT
5New L .Modification ❑Complete Reissue
0
a
Partial Reissue
08501 A
Previous permit #
Date previous permit issued
sized by the State of North Carolina, Department of Environment and Natural Resources
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC04 H -11 b
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❑ Rules attached.
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.ocal Planning jurisdiction)

Name of Property Owner Requesting Permit:
Mailing Address:
Phone Number: /O'" Z3 �(W7
Email Address:
I certify that I have authorized Jim O'DanielllPort City Maintenance ,
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development:
at my property located at
in New Hanover
County.
i furthermore certify that i am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signature
/moo el-? CF IVC6L,,,
Print or Type Name
Title
8 1.2,G l�
Date
This certification is valid through ? 1�17-

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: " K,
Address of Property: _�o / % /�%,� e N S© a
(Lot or Street #, Street or Road, City & County)
Agent's Name #: �. off— Mailing Address:
Agent's phone #: gya -14 z-4y�l
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 proposing. 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.)
1 do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
7A--
Signature
Print or Type Name
49.17 ,m w. kxw,<:;-a-0
(Ad1j,"t Property Owner Information)
(��hature `
JoA,
Print or Type Name
Mailinn drlrinoec
AA -;I;..... A-1.J----

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent toQ��jdlQ
G117 (Name of P p rty Owner)
property located at _ ! ill�s� �ou� s,, �, , e
on�uJ�✓�7f �� (Address, Lot, Block, Road etc.)
in , e'wf- V% N.(
(Waterbody) (Ci /Tow and/or County)
The appli/cant has described to me, as shown below, the development proposed at the above Ii
y I have no objection to this proposal.
I have objections to this proposal.
uL5GRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must�ill in description below or attach a site dray+
��
s'ee &4Lal�
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish t(
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 Owner Information) (Adjacent Property Owner Information)
l�
Signature Signature
/ In9or Type Name Pnnt or Type Name
w 7 i?A�i_..•)L_�. /_rimer ._ 1 �� n

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