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-(CAMA / L -11 DREDGE & FILL 6,17
�% ENERAL PERMIT Previous permi I t # A B
ew I —Modification OComplete Reissue EPartial Reissue Date previous permit issued
rized by the State of North Carolina, Department of Environment and Natural Resources
-oastal Resources Commission in an area of environmental concern pursuant to 15 61P. Aco
E:1 Rades attached.
it Name Project Location: County--N e I'l, " )�A. 1"'I 0-ve 1
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ed Agent
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)g permit may be required by: J L w HA P1.0 h/(NL�ote on back regarding River Basin r
-ocal Planning jurisdictiog),

NC Division of Coastal Mgt. Habitat Impact Coml
Applicant: Pkrft il 'J
Date: <
Describe below the H BITAT 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
FII'
(Applied for.
(Anticipated final
(Applied for.
(Ar
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disl
Habitat Name
Choose One
includes any
Excludes any
total includes
Exc
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
ten
temp impacts)
impact amount
temp impacts)
am
Iv
Dredge ❑ Fill ❑ Both ❑ Other
z- 0
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
i
i
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

Pat McCrory
Governor
WIXNR
North Carolina Department of Environment and Natural Resources
N.C. Division of Coastal Management
John E. Skvarla, III
Secretary
AGENT AUTHORIZATION FORM
Date: miJ ,&/ Ou)
ame of Property Owner Applying for Permit: Name of Authorized Agent for this project:
Dwn:4em
'Mailing Address: Agent's Mailing Address:
�Jjr/&
Vkl At Y t tf im Aa
P.O. Box 868
:-mail.- %il e-& % D y�� /,,�.• 284�f
/rYl /1 �.i51i7/L1J�S LLUyN Email: ,,,, „% nrn nnnn
'hone JO ) 15" 66V (
Phone
certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
or, and obtairtMg all CAM.4 Permits necessary to install or construct the following (activity):
=or my property located at llc( rY&T5 HC--I&
'his certification is valid 1 year from (date) � / Iona )M
& S/ffawo Coow. ,
P.O. Box 868
WrightSVille, Beach. NO 28'
(910t 250-3062.
U r v �P f2y I )

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: Jltv)b / /l &M-g-w
Address of Property:
(Lot or Street #, Street or Road, ity County)
Agents Name #: L 'J ` Mailing Address:
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 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 Certifie# Mail_
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, bo thouse, 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 Owner Information)
A _ l �- t ►- ' .---
Signature
Print or Type Name
(Adjacent Pro rty Ckuner Informations /
u�
Signai`14
Z6114
Print or Tye Name

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner. ��1�1 / 1'd &x7r6 l
Address of Property: /d 4&14 M-1lL A/
(Lot or Street #, Street or Road,
Agent's Name #: GL'c�
Agent's phone #: /)d' d7 " -, d
U,�- 9V+
County, )�
9 Q
Mailin Address: ' " G4 vd
U&, �M-3 Mj4 Al,C. 28 y
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
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 Owner Information)
Signature
ORVio M �P�
Print or Type Name
(Adjacent Property Owner Informationv
�ga �Airk
Tl� 4

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