69400D - Lucera

,CAMA / DREDGE & FILL (��� v NO 69400 A B
GENERAL PERMIT Previous permit#
)New --j Modification �L ]Complete Reissue C Partial Reissue Date previous permit issued
ized by the State of North Carolina, Department of Environment and Natural Resources I Iwo
oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC (JEJ
+ A r ❑Rules attached.
Name �oN l.yL-IC-1 J �� Project Location: County PENor_ i
��,,�©V coos ``v" Y Street Address/ State Road/ Lot #(s)
l5k I�7 State W-., ZIP 2 � �J kut'
qn)'N� f `$Z E-Mail Subdiv��PD�p
*
ad Agent `/V�, TL{t= c4jla�k.�>►.?TS CityZIP 4_16 C
❑ CW '�,IEW ABTA El ES ❑ PTS Phone # (_"�� River Basin ��
❑ OEA ❑ HHF /❑ IH ❑ UBA ❑ N/A
❑ PWs: Adj. Wtr. Body _�f 7p'Cjl-' �
res //,ice PNA es j Closest Maj. Wtr. Body �Z�PS�IL ��AD y
Project/p►y>;ivity 4 M+ ( �A-Ct ��0� -G)C4
k)length ff
tform(s) 7
3latform(s)
/ RipraN,
distance\i
c distance
annel
is yards
P
1
Length
not sure yes no
im: n/a yes / no
yes o
ttached: es
g permit may be required by:
ocal Planning jurisdiction)
- .�- Jul ■■■I %�11
y
■
(Scale:
FT7_7;�;
❑ See note on back regarding River Basin

Letter of agent
1 bm,d [(;C c7 `` ___ have retained Mark Clements DB A. Clements
Marine Construction Inc. to make application for any and all permits needed to start
construction on the work requested for our property or properties.
By allowing Mr. Clements to make such applications I do understand that this will in no
%vay relieve me of any obligations to perform all work according to the building codes of
North Carolina, LAMA, DWQ or any other state and or county ordinances.
.T) ONNa) v ,' ,A
Pl'llll nallle
Signature L�
LO-a 1<date
Contact mfonnation
tic
lid-�$�'

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIERIMOORING PILINGSBOATLIFTB%OATHOUSE)
I hereby certify that I own property adjacent to l�� G rr1(._�7' is
(Name of Property Owner)
property located at
(Lot, Block, Road, etc.)
on r Z7 ,'-, , , in ,
(Waterbody) Vol" and/or County)
Applicant's phone #: � /1 �ZC � _ Mailing Address:,
He has described to me, as shown below, the development he is proposing at that location, and. I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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 not wish to waive
jf. I do wish to waive that setback requirement.
------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be filled in by individual proposing development)
efCAO"
(Information for Property Owner Applying
for Permit)
l/ 2 cz/ c; le t
Mailing Address
/ A - z7f
City/S to/Zip
(Riparian Property Owner Information)
T Signature
Print or Type Name

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
(FOR A PIER/MOORING PILINGSBOATLIFTBOATHOUSE)
I hereby certify that I own property adjacent to _ l7- (/(,.e- — � is
(Name of Property Owner)
property located at �Z&,�z_
(Lot, Block, Road, etc.)
on iez �i'�ii, in � �� , N.C.
(Waterbody) (, own and/or County)
Applicant's phone #: !UZZO %�Mailing Address:
He has described to me, as shown below, the development lie is proposing at that location, and. I
have no objections to his proposal. I understand that a pier/mooring pilings / boatlift / boathouse
must be set back a minimum distance of fifteen feet (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.)
�j J I do not wish to waive
,lt�/ � I do wish to waive that setback requirement.
-------------------------------------------------------------------------------------------------------------------
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT:
(To be fillet! in by in(livitlual proposing development)
(Information for Property Owner Applying
for Permit)
le
Mailing Address
City/S to/Zip
(Riparian Prolverty Owner Infor ation)
Signature
P mt or Type Name

USPS Tracking®
d a tracking number
70162710000101377241
Delivered:
HAMPSTEAD, NC 28443 on
August 30, 2017 at 12:54 pm
Updated Delivery Day:
Wednesday, August 30, 2017
70162710000101377258
Delivered:
HAMPSTEAD, NC 28443 on
August 30, 2017 at 12:54 pm
Updated Delivery Day:
Wednesday, August 30, 2017

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■ 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,
or on the front if space permits.
I. Article Addressed to:
A. Sift,
X wl/L
❑ Agent
❑ Addressee
B. Rec ived by (Printed Name)
C. Date of Delivery
D. Is del ry address different from item l?
❑ Yes
uJf YE�enter delivery address below.
❑ No
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oa
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IIII III III I IIIIIIII III III I I I III 3. Fervi pe El
Elt Adult Si"re Restricted Delivery ❑ Registered edlMailRestricted
9590 9402 2377 6249 9968 08 Certified Mail(D Delivery
❑ Certified Mail Restricted Delivery ❑ Return Receipt for
❑ Collect on Delivery Merchandise
2. Article Number (Transfer from sPrvira fahail ❑ Collect on Delivery Restricted Delivery ❑ Signature ConfirmationTm
7016 2 710 0001 0137 7241 )sured Mail ❑ Signature Confirmation
)sured Mail Restricted Delivery Restricted Delivery
,)ver$500)
PS Form 381 i , July 2015 PSN 7530-02-000-9053 Domestic Return Receipt
■ 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,
or on the front if space permits.
1. Aticle Addressed to:
A Amla /fir
I I IIIIII IIII IIIIIIIIIIII IIII I II I I I IIII
9590 9402 2377 6249 9967 92
A. Sign4ture
B. a ived,
N N
O O
v �
N D
❑ Agent N
❑ Addressee CO
m
C. Date of Delivery
D. Is Oiveryaddress different frdm item 1? ❑ Yes
If 14rU, enter delivery address below: ❑ No
��
n' Z
G� <
_.� M.
3. -Servi(Z Type ❑ Priority Mail Express®
❑ Adult V� ture ❑ Registered MaHTM
Wdult St�pature Restricted Delivery El Registered Mail Restricted
Certifie ail(D Delivery
1 ❑ Certified Mail Restricted Delivery ❑ Return Receipt for
❑ Collect on Delivery Merchandise
2. Article Number (Transfer from service label) ❑ Collect on Delivery Restricted Delivery ❑ Signature ConfirmationTM
ured Mail ❑ Signature Confirmation
7 016 2 710 0001 0137 7258 ured Mail Restricted Delivery Restricted Delivery
er $500)
PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Return Receipt ;
41.
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