66379D - Mobley

CAMA / ❑ DREDGE & FILL ,� �--1 � 66379 A B i
iENERAL PERMIT Previous permit #
New ❑Modification ❑Complete Reissue El Partial Reissue Date previous permit issued
zed 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 (� l F-1 Ryles attached.
Name i�J�u' ► r` Project Location: County * i �f12�
Street Address/ Stat oad// t #(sk;'�
S Staie ZIP �v , i
r:1 ___�_
E-M it
Agent
:d
❑ CW
LTA ❑ ES ❑ PTS
4HHF
ElOEA
❑ IH ❑ USA ❑ N/A
❑ PWS:
yes
PNA .`Yes / no
Project/ Activity
(Scale: p4_ 2
ZIP
City,��i(
Phone # (
Adj. Wtr. Body /'
Closest Maj. Wtr. Body
:k) length
atform(s)
Platform(s)
ier(s)
ngth
mber
d/ Riprap length_
g distance offshore_
ix distance offshore
hannel
,e Length
not sure yes `o
mum: n/a yes (no
Yes no
ling permit may be required by:
I nral Planning Jurisdiction)
❑ See note on back regarding River Basin

1lGl:G1VGU
I "U VJ11GU
I kimumv)numer
I irumber
I amount
ommen s
5/3/2017
Patrick Antinori
Randell Mobley
First
1023
$200.00
GP 66379D
Citizens
Bank

N�WDIIVI/S�1i9�11 ®T 41dQa' 5T-•ai'.111V&* S1Ltllaa a�.a� a.sa�em--• - - ..
Applicant: QALxC
Date:
Describe below the HABITAT disturbances for the application.
All values should match the name,.and units of measurement found in. your Habitat code sheet.
S Pt FINAI Sq Ft. TOT
TOTAL q.
(Applied for.
(Anticipated final
(Applied for.
(An{
DISTURB TYPE
sturbance.
Ditotal
includes any.
disturbance.
Excludes any
Disturbance
total includes .
disc
Exc
Habitat Name,
Choose One
anticipated -
restoration
any anticipated
resi
restoration or
and/or temp
amount)
restoration or
tem !. acts
tam
am(
temp. impacts)...impact
w
Dredge ❑ Fill ❑ Both ❑ Other
l
Dredge CI Fill ❑ Both. ❑ Other
Dredge ❑ Fill ❑ : Both ,❑ Other El
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill 171. Both ❑ Other ❑
Dredge. ❑. Fill ❑ : Both ❑ Other ❑
�;_;.
Dredge ❑ Fill ❑ Both ❑• Other [3

N.C. DIVISION OF COASTAL MANAGEMENT
AGENT AUTHORIZATION FORM
Date , 6 i —,J, L o) l
Name of Property Owner Applying for Permit:
RCW 6&
Mailinn AAA—.-
I certify that I have authorized (agent( LJ� wrc),Z.` to act on my
behalf, for the purpose of applying for and obtaining all CAMA Permits necessary to
install or construct (activity) 606—�
at (my property located at) 53 j �1� �,,� 1 k S*Yf,� bq.
5t,jcz(k� --refful i\c.c_ 2-.4640C
This certification is valid thru (date) Cif 1 1 15 7—C I B
/,--a/.S'i
Property Owner Signature / ! Date

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property
Address of Prope
Agent's Name #:
Agent's phone #:
Agent's email:
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.)
_ I do wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property
Si
gnature
iV k
Print or Type Name
is io^ — FO H- K, n 0.
Mailing Address , ✓� 1
(Adj t Prop rty Own for ati )
C
Signature
Al�
Print or Type Name
PD. 6oX 33c�
Mailing Address

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIP - -- ---- -
Name of Property Own
Address of Property:
(Lot or Street #, Street or Road, City & County)
Agent's Name #: �)no+Ltz. C-i Mailing Address: Z-ILI 71t f6S C&
Agent's phone #: " 3S�' 55CD S-iu.. p V '1 J c i�{ (2 a 5l4 l>
Agent's email:
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
R
roposing. 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.)
I do wish to waive the 15' setback requirement. , f
I do not wish o t waive the 15 setback requirement.
(Prerty Ow er Informatio
0
Signature /
e -
Print or Type Name J% }
&14 d 3 f�►ry C�.
Mailing Address ,
(Adjacent Property Ow Information)
rgnature
Print or Type Name
exr,4i11:ad-
Mailing Address