69045D - Martin

I,FAMA / ❑ DREDGE & FILL 696 A B
'ENERAL PERMIT y13 ��� 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
❑ Rules attached.
t Name ��%��^e - !' �` "� Project Location: County__JP,
(.LVA-Q Street Address/ State Road/ Lot #(s�
CLVV%4— State ZfP `' "
() Q� E-Mail ��1'�� �V ��c�"•' Subdivision
,ed Agent ��i��i wr V�QJ� COWI City � U ZIP
❑ CW �EW PTA ❑ES ❑ PTS Phone �F ( LO ) l ^ ' , � Riiiv�/ Basin �l �
❑ OFr4 ,❑ HHF ❑ IH ❑ UBA ❑ N/A Adj. Wtr. Body r Ryi KJt (nat /i
❑ PWS:
yes / n(9 PHA yes /
f Project/
)ck) length /
latform(s)
Platform(s) �`rS x
mgth
ember
id/ Riprap length
Ig distance offshP
iax distance ojfsh
:hannel
jbic
.use/ Boatlift
Bulldozing
ine Len
not sure yes
:)rium: n/a yes
yes
Closest Maj. Wtr. Body "lU-
1'
(Scale: I
r Attached: yes I 10, 1 '
r fit,,N k Y 9
ding permit may be required by: ' iJWh 0{ LYa
I __-I Dl...........
❑ See note on back regarding River Basin
n

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4
COMPLETE•N
MU01144iffIr THITTECTIONON DELIVERY
0
;omplete items 1, 2, and 3.
A. Sigu
v
'rint your name and address on the reverse
❑ Agent
o that we can return the card to you.
El Addressee
,ttach this card to the back of the m �DpudB
r on the front if space per
d nted Na C. Date of Delivery
1� !� �/ t, I - -5 —1 (o — t -7
rticl(e,A,d�dresssse�d to:
� I Q
D. Is delivery ddress driyfferent from item 1? ❑ Yes
e.NeI.ad`�`��Sbelo . nt ❑ No
))o "-r �j� y
�,
U) � �
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s`N�
(D a
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3. Service Type ❑ Priority Mail Expresso
n
(�IIIII IIII �I I II �I I I II I II ( I'I I I
❑ Adult Signature ❑ Registered Mail-
0 Adult Signature Restricted Delivery ❑Registered Mail Restricted
9590 9402 1363 5285 8760 20
❑ Certified Mails Delivery
El Certified Mail Restricted Delivery C Return Receipt for
rticle Ni imber Transfer from service label)
❑ Collect on Delivery Merchandise
❑ Collect on Delivery Restricted Delivery 0 Signature Confirmation —
Signature
Confirmation
7 015 0920 0000 7 610 4103 Delivery RestrictedDelivery
�
orm 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt
(D
00
co
90
■ Complete items 1, 2, and 3. A. Sig re
■ Print your name and address on the reverse
so that we can return the card to you. - Agent
■ Attach this card to the back of the mailpiece, ddressee A
or on the front if space permits. 0e by (Printed ame C)
C. Dat of De' ery p
1. Article Addressed to: /Q C)/7 /� , • n Is delivery address different from item 1? ❑ Yes
/) W✓ �^ ///�V (/ +� If YES, enter delivery address below:
rV
CD
o
o
�9590
IIIIIIII'�3. Service Type O)
❑ Adult Signature ❑ Priority Mail Express®
❑ Adult Signature Restricted Deliv Registered Mailr"-41
❑ Certified Mail® EJ Registered Mail Restricted Ut 9402 1363 5285 8759 93 11 Certified Mail Restricted Delivery Delivery o
❑ Collect on Deliv ry 13 Return Receipt for y
!. Article Number (Transfer Irom service label) ❑Collect on Deliv R.
Merchandise
ry estricted Delivery El ConfirmatlonTM
7 015 0920 0000 7 610 4097 Signature Confirmation
— Restricted Delivery

NC Division of Coastal Mgt. Habitat Impact Com
Applicant: Doan`— �(,tt! Y,
Date: 0 / a � /� 017
Describe below the HABITAT disturbances for the application.
All values should match the name, and units of measurement found in your Habitat code sheet.
TOTAL Sq. Ft.
FINAL Sq. Ft.
TOTAL Feet
FI
(Applied for.
(Anticipated final
(Applied for.
(A
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
di:
Habitat Name
Choose One
includes any
Excludes any
total includes
E
anticipated
restoration
any anticipated
re
restoration or
and/or temp
restoration or
to
temp impacts)
impact amount)
temp impacts)
ar
/
U `/V
Dredge ❑ Fill ❑ Both ❑ Other
0g
?'
C rrfI
t'6
J
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

JJ'Ar
NCDENR
North Carolina Department of Environment rand Natilral ReSri�lr�.es
AGENT AUTHORIZATION FORM
Date: j 5
e of Property Owner Applying for Permit
sr's Mailing Address:
wfvc A )4 P4
7949
t��Gv f�� f'J��D '' �j'a^a r � . C�S�'►�!
Donald R van der Va
Secretary
Name of Au , orized Age'pt4or this project:
n7 C:�,
/-fjY
Agent's Mailing A dress:
Email: /lJ !%
Phone
ify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
nd obtaining all CAMA Permits necessary to install or construct the following (activity):
iy property located at
:ertification is valid 1 year from (date)
1— 0
Z/Z 51�1-7

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Individual Applying
For Permit: 1 il�l�- r L-\
Address of Property:
(Lot or Street #, Street or Road)
D3L l - Ba-A , «k
(City and County)
ere y certl that I own property adjacent. tote above -referenced property. The indivic
applying for this permit has described to.me as shown on the attached drawing the.development t
Are proposing. A description' or drawing, with dimensions, should be provided with this letter
v
I have no objections to this proposal.
f you have objections to what is being proposed, please write the Division of Coa
Management, 127 'Cardinal Drive Extension, Wilmington, INC 28403 or call 910-796-7
within 10 days'of receipt of this notice. No response is considered the same as no.objectic
you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house orboatlift must b
bck a minimum distance of 15' from my area of riparian access - unless waived by me. (If
wish to waive the.setback,*you must initial the appropriate blank below.)
I do wish to waive the 1 5' setback requirement.
�4X4� I do not wish to waive the 1 5' setback requirement.
; Sign Name Date
AVI A

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Individual Applying For Permit:L
Address of Property:
$-3L
(Lot or Street #, Street or
(City and County)
S—)—
hereby certify that I own property adjacent. to the' above-referencedabove-referenbed property. The indivi(
applying for this permit has described to.me as shown on the attached drawing the.devetopment
are proposing. A description or drawing, with dimensions, should be provided with this letter
X60 . I have no objections to this proposal.
If. you h,
Managen
within 10
you have
no
,—I U-J� S-�-- (-�
-ite the Division of COD
28403 or call 910-7964
d the same as no.objectic
? underst _S j �-- ��Y C house or boat lift must b
bcka mij - unless waived by me. (I1
wish to V v �C-� % ��C�C�t� 1k below.)
nent.
Sian Name Date
V
AIPWw

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