68206D - North

4CAMA / ❑ DREDGE & FILL
ENERAL PERMIT �� " Previous permit A B
p �
kNew Modification ❑Complete Reissue ❑Partial 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 I SA NCAC_�
❑ Rules attached.
it Name M R T1 H l w t-3
I �-- k�R�l �<' Iyc
_i
State , _ ZIP
E-Mail
:ed Agent VAT, (z (Gj- t 1VJiIMCfl
❑ CW �fm PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ H ❑ UBA ❑ N/A
❑ PWS:
yes //fi$) PNA yes 4no
Proj��e--ct/ Activity (M� al
ck) letisl
itform(s)
Platform(s)
ve
ier(s)) `�
ngth�7 �-h�Q 2
�— —
'nber
i/�p length
distatipraa offshore
x distanc�ffshore
cannel
)ic yards
'p'
oatli , Z �Z
Length
not sure yes
no
um: n/a yes
.+sC
yes
now
,ttached: yes
no _
Project Location: County ("+'\ ,. 't"!
Street Address/ State Road/ Lot #(s)
3kl S d l)t c- MA4ZI ►
Subdivision C '
CityC,cd S- wf ZIP Z`d
Phone # ( �RiverBasinWJJJE
Adj. Wtr. Body iN IC
-j , �nI
Closest Maj. Wtr. Body 0 E'J 0 Ut (L'"
21 c,2U
(Scale: I (I- I
ig permit may be required by:See note on back regarding River Basin
.ocal Planning jurisdiction)

NC Division of Coastal Mgt. Habitat Impact Coml
Applicant:
Date: �%✓ , Z�
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.
(Ar
DISTURB TYPE
Disturbance total
disturbance.
Disturbance
disc
Habitat Name
Choose One
includes any
Excludes any
total includes
Ex(
anticipated
restoration
any anticipated
res
restoration or
and/or temp
restoration or
ten
temp impacts)
impact amount)
temp impacts
am
Dredge ❑ Fill ❑ Both ❑ Oth
2 c(
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Applying for Permit: ► `�"�� �� `�
Mailing address: 17 QrA� 7j2 r,►-�
5NeA-Ps -e,eq AIC 28Y(,o
Phone Number: q!0'FS9— 1��1
I certify that I have authorized 1' 1 I' �
� iltN
Agent / Contractor
to act on my behalf, for the purpose of applying and obtaining all CAMA permits
necessary for the proposed development of
at my property located at Riw5YqD,rw— AIW2 40-
in 01/US10ty
County.
This certification is valid through 101 I 3S—A]
Date
(Property Owner Information)
Si nature
/VAAe,., E-, k LJ-�,-
Print or Type Name
Title
7— 3—
%

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner: / ' 1 q--*� f, E, lyo o,+t
Address of Property:
Ay -D 2i V C- -. Siv e 44D_
(Lot or Street #, Street or Road, City & County) r
Agent's Name # *9J Cl- AINVIMw Mailing Address:2Z�i PG 0.
Agent's phone #: Ct I - 3 —6 5Ul? mac_ tZAIV (�1P, M ,e- 7—%Sgo
Agent's email: D.a,.CW4VU dlOt4 It) nrA1 W1 \
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.
J K 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
10
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.)
x � I do wish to waive the 15' setback requirement. Rcyj 1,4-4 slip
tU (�
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
- - Ant��
t -
Signature
/667
Print or Type Name
l -7 Ri4, Aoi'v C-
(Adjacent Property Owner Information)
4j6v�
Signature
I�A,7-a-VEY W. boo PS ►�—
Print or Type Namel
z©gq Dove -
Mailing Addres
Mailing Address

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAIVER FORM
Name of Property Owner:
Address of Property:
(Lot dr Street #, Street or Road, City & Cou
AIC-. 0A1_9 &--)
Agent's Name#: �I 1C.C� �l�lli�tt)(LI Mailing Address: Llti (ipjrflJ G" �L
Agent's phone #: 0' 33D- 5S,00 1�1 c
0
Agent's email: 0,0..Cpn6tm ►o:4 @1 n1CC,\ ,CDYY\
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 p oposing. 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 tow ive the setback, you must initial the appropriate blank below.)
I do wish to waive the 15' setback requirement. U� L� I I s I 66
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature '
Print or Type Name
7 6AY �2
(Adjainent Pro rty O ner Information)
V �
Signature
C"oN2)Z W t 1 s'oAJ
Print or Type Name
1 15r5 y 4(z4w 1 q-f- tW4
Mailing Address
Mailing Address

1
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