69247D - Hill

CAMA / ❑ DREDGE & FILL �.� ' A B
GENERAL PERMIT Previous permit#
'Jew Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
I-ized by the State of North Carolina, Department of Environment and Natural Resources1500 (67
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
El Rules attach
t Name Project Location: CountySIM
(. Street Address/ State Road/ Lot #(s)
In St t ZIP d (64-- .?U OAS
ae
E-Mail �—
:ed Agent
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Y?TA ❑ ES ❑ PTS
❑ OEA
El HHF
❑ IH ❑ UBA ❑ N/A
❑ PWS:
yes / pion) PNA yes /
f Project/ A
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>ck) length_
latform(s)
Platform(s) -
angth
ember
ad/ Riprap len
(g distance offshore
iax distanceADffshore
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ubic
tm
Boatlift
Bulldozing
c
. { 3 C'
ine Length I S
not sure yes
orium: n/a yes
yes
r Attached: /�s no
ding permit may be required by:
Subdivision i 1
A€(�Ce ayi i ZIP
ry�1'
Phone # �7a`i) �' River Basin 1A)
Adj. Wtr. Body �✓l nat
Closest Maj. Wtr. Body
Ace njvl!J( c i, o C
rj (Scale:)
jj 1 O�Rd'tV -, 6tqr Y ❑ See note on back regarding River Basin

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AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit
Mailing Address: ? u
Phone Number:.
Email Address:
I certify that I have authorized
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 _ u.^ County.
l furthermore certify that 1 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
Print or Type Name
Title
C— A ,

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
C�
Name of Property Owner:
Address of Property:
(Lot or Street #, Street or Road, City & County)
Agent's Name #: ��I G y 61 m Mailing Address: 1
Agent's phone #:
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.
VI 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. Contact information for DCM offices is
avallable athttp://www.nccoastalmanagement.netlweb/cm/staff-listinorby calling 1-888-4RCOAST.
No response is considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, cock, mooring pilings, boat ramp, breakwater, boathouse, or lift 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.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signatu e `
r,;� , - Ax L-L
Print or Type Name
Mailing Address
(Riparian Property Owner Information)
C� Signature {
Print or Type Name
Mailing Address

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or Street #, Street or Road, City & County)
Agent's Name #` /S c%t (,JCS
Agent's phone #-. 7 D (�' -3 6 -3 "L;
r7 G
Mailing Address:. r
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. j
} ff ydiu 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. Contact information for DCM offices is
available athttp://www.nccoastalmanage en t. netlweblcmls taff-lis tin orby calling 1-888-4RCOAST.
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, boat ramp, breakwater, boathouse, or lift 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.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
'
Signature
7� Ll
Print or Type Name
Mailina Address
(Riparian Property Owner Information)
v Yt cc_ _
Sign ure
nl lip �l ItJ C-.cL
Print or Type NArne
(� �+ 4,,
Mailina Address

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