69290D - Jensen

LAMA / ❑ DREDGE & FILL
iENERAL PERMIT Previous permit#
New :]Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
ized 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 <J7 �� 0 (D
❑ Rules attached.
Name 1-1 Project Location: County K CIM SLAA
1 Street Address/ State Road/ Lot #(s)
In l 1 StateZIP C)Z N, ,S�xoit br
(T '' 0 5 E-Mail 1 i
!d Agent C%_zt ( 6V1 IY1/[ t►-bw1
❑ CW ;OW XPTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS:
res /(no ) PNA V / no
Project/ Activity
k) length
tform(s)
'latform(s) ,� n
igth
,iber
/ Riprap length
distance offshore
c distance offshop
annel 7
is yards
p
;e/ Boat
illdozing
YJ f
Length J V
not sure yes
um: n/a yes
yes
attached: yes
Subdivision /,,
City �j2'Gl ( ! ZIP
Aone # ( Q) 57'i `� O IQ River Basin (Ill"
Adj. Wtr. Body_g I Gt Y,t a /n
Closest Maj. Wtr. Body AiUlln i
(Scale: I"—, Z
i
ig permit may be required by: TOV.A1 0 ,S�'tS{ T �7C �� V' ❑ See note on back regarding River Basin rt

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■ Complete items 1, 2140d 3.
■ Print your name and dress on the reverse
so that we can returrohe card to you.
■ Attach this card to'th!O,back of the mailpiece,
or on the front if spdce•permits.
1. Article Addressed to:
� r_ot, \ —\3D OW\ Q�-
COq-��►�
�u�r ►.,bury 2�� 35�
9590 9402 2219 6193 1025 74
A. Signature
X r ❑ Agent
If ❑ Addresse
B. eived by (Printed Name) C. Date of Deliver
�'lU-�u� r_� • vtci
D. Is delivery address different from ifem 1? ❑ Yes
If YES, enter delivery address below: ❑ No
L❑3. ElService Type Priority Mail Expresso
❑ Adult Signature ElRegistered Mail -
Adult Signature Restricted Delivery ❑ Registered Mail Restrict
ertified Mail® Delivery
Certified Mail Restricted Delivery -VPRetum Receipt for
❑ Collect on Delivery Merchandise
2. Article Number (Transfer from services lanall ❑ Collect on Delivery Restricted Delivery El Signature ConfirmationT
7016 0600 0000 8200 4792 vlail ❑ Signature Confirmation
vlail Restricted Delivery Restricted Delivery
Ttover woo)
PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Return Receip
a
L------------------------- �---------------
■ Complete items 1, 2, and 3.
■ 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,
0 0 or on the front if space permits.
O U U 1 ArTirle Aririroceeri 1n•
o,� , a .r•j� . Uv Postmari
LE]
tifiedMailRestrictedDellvery $$4 `lo Here
lt Signature Required $t,4()lt Signature Restricted Delivery $
e
W.49
Total Postage and Fees
$ $6.59
�'sCZ�IP - -�
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UIt �Ull,'c Of-
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A. Si tuts
Agent
❑ Addressee
.!�.-*ceived by (Prin am) C. Date of De ery

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Pat McCrory Braxton C. Davis John E. Skvarla, III
Governor Director Secretary
AGENT AUTHORIZATION FORM AGENT AUTHORIZATION FUKM
Date: 14.2 i),/_
am�e of Pro Owner Applying for Permit: Name of Authorized Agent for this project:
wner's Mailing Address:
1- i Lq i'bE,ZuJoo0 L-q le-
C►_4 A -Pc L t- , L L 01 a'7 51'%
lone Number (q A Cl & 1,7 - 6 405-
Agent's Mailing Address:
btelB
CC C I I I J s Lr
Phone Number (� io) 59 q q Ua-S
:ertify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
r and obtaining all CAMA Permits necessary to install or construct the following (activity):
)r my property located at 8 Ua r) ,;,' i,4 S iq o,Z L �1 F
SJ rl. 5E 1 -3E fie►`, +� C o2e4/66-
its certification is valid thru (date)
l C 41
Property Own r ignature Date

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROP15RTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: Tr 1 c �L ►l�k n
Address of Property: WZ `` *) 5h6rQ u nuexQ� eogc )
(Lot or Street #, Street or Road, City & County)
Agent's Name#:�rtC� `U,I'UL�I�� MailingAd-d-ress:6��aQLh t�
Agent's phone #: "���- J-1G "9b95 �1n - 6 Q UEC�\ N( 2-<64(,q
I hereby certify that I own property adjacent to the above referenced property. The individual applying for
this permit has described -te-me as shown on the attached drawinq the development they are proposing.
I have no objections to this proposal. I have objections to this proposal.
if you have objections to what is being proposed, you mus no the Divi " n of Coastal
Management (DCM) in writing within 10 days of receipt of this notice. Corres a should be
mailed to 127 Cardinal Drive Ext., Wilmington, NC, 28405-3845. DCM represent eon also be
contacted at [phone]. No response is considered the same as no objection #` /" been
notNied by Cert/fied Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse,, iff, 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 16' setback requirement.
I do not wish to waive the 15' setback requirement.
'(,Property Owner information)
Signature
`-" n �
Print or Type Name I�
, V� LAn� Cl> �d �. N
Mailing Address
N00A \Q� N( Zis)q
ity/State/Zip
(Adjacent Property Owner Information)
Signature
Print or Type Name '
i0� /old/f�t�oie %fir. e)d'
Mailing Address
SQnse�r� , Al
City/State2ip _

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:
Address of Property: W� �y 1 ��� r� �)U ilk I�eC► )
(Lot or Street #, Street or Road, City & County)
Agent's Name #:Gr
t��5�('U( �IU�
Agent's phone #:
Mailing Address-.61 I k_32QCh
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_ I have no objections to this proposal. 1 have objections to this proposal.
If you have objections to what is being proposed, you mus-f-nofify 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 representadvos can also be
contacted at [phone]. No response is considered the same as no objection if you h" been
notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse-,lift�-o-rgroin 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.
_ 1 do not wish to waive the 15' setback requirement. wv( t_� S %S
(Property Owneerr Information)
��A,rj
Signature
Print or Type Name
IM LA► A4ck�o4 Uy
Mailing Address
1 Q� N ( Z-7 S) LI
ity/Stdte2ip
(Adjacent Property Owner n o mation)
Si nature
4L
Print or Type Name
Ko
Mailing Address
City/State/Zip 24i?sl

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