68535D - Kelley

A"/'. IDREDGE & FILL 11DT A �$I '9535 A B
�E N E RAL PERMIT �' Previous permit #
ew �iModification ❑Complete Reissue El Partial Reissue Date previous permit issued_
•ized by the State of North Carolina, Department of Environment and Natural Resources o ��! I
:oastal Resources Commission in an area of environmental concern pursuant to I SA NCAC I j f� i)
1 ❑Rules attached.
Name 1 Gl ((.. Project Location: County &,(�M—Sj,�Vi (k
1 Yl Street Address/ State Road/ Lot #(s)
f State zip `L gi' U
— 0 Mail 0 (subdivision G
ed Agent City Li V1 K i �i ZIP ZZs "I
❑CW ?TA DES ❑PTS Phone # ( ) River Basin �Y
ElOEA ElHHF /❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body '` t at n
El PWS:
yes / a
PNA yes / Closest Maj. Wtr. Body
(5 -7 6A 7­
Project/ Activity Y1 6�14 4 G(
0—
:k) length
tform(s)
V / '�
'latform(s)
igth
nber
I/ Riprap length_
distance offshore
< distance offshore
annel
is yards
ip
,e/ Boatli
illdozing
IMMO
:Length S
not sure yes
um: n/a yes
yes
ttached: 6 no
ig permit may be required by: �W r ` 0 ❑ See note on back regarding River Basin
.ocal Planning Jurisdiction) .^ A t

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:
J
Mailing Address: C6 �S�►'� �p G'
1�1/ .� G g
Phone Number:
Email Address: tt'�i 0kt Ile i,/7,� IV arn1.,e-b,,
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: Kt co Y%oo,—r r . r-jos=&
Lf
n
at my property located at 5_3
Tel
County.
1 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
V
Title

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: -- ;+--'1 ,
Address of Property:
(Lot or Street #, Street or Road, City & County)
Agent's Name #: —:Yx r2d ryN Mailing Address: htLf L O�'a'In R-0c
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.
A,, 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.
1 do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
Print or Type Name
Mailing Address
(Adjacent Property Owner Information)
Signature ' 4-
Name
-03S3
Mailing Addre-4
/1, - --eI _n- w%l -1nVAh

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �'s
(Name of Property Owner)
property located at ,2'3 S�A,�.,.,i L- / 3�s
on 0ltl so"; y C,e,eG
(Address, Lot, Block, Road, etc.)
, in � �,,(�, l i3r�.. N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above local
s 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
Cn c-) Kin c
If
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set ba
minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to w
tpe 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) (Adtace trgroperty Owner Information)
Signature
Print or Type Name
'9ailiw Address
Signature
yr,e
5 1 orSTGame
f1V1r? 1?Q � J-
AA�ili- A.l.-1-:-

0
f _ o
L.
1. Article Addressed to:
07& 3
3 A. Signature
f / , ` ❑ Agent
)ss on the reverse X �(�(��
yard to you. ❑ Addressee
;k of the mailpiece, B. Received by (Printed Name) C. Date of Delivery
rmits.
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
Service Type
❑ Priority Mail Express
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El Signature
El
aiIT""
❑ Registered Mail-
❑ Adult Signature Restricted Delivery
❑ Registered Mail Restricted
9590 9402 3306 7196 3495 93
Certified Mail®
❑ Certified Mail Restricted Delivery
Delivery
❑Return Receipt for
l Cnl Fl—+. Delivery
Merchandise
7 016 0 910 0002 1225
Delivery Restricted Delivery
91355 ril
❑ Signature Confirmation-
Ll SignatureConfirmation
u insured Mail Restricted Delivery
Delivery
ry
(over $500)
PS Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt
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