68020D - Priest

KI�AE/GE &FILL J - � �-. �-• ;-, I A B
PERMIT 7 Previous permit #
❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
>rized by the State of North Carolina, Department of Environment and Natural Resources (t DC) j
Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC t
Rules attached.
-it Name ` j Project Location: County
V Street Address/ State Road/ Lot #(s)
State ZIP
Mail Subdi)(ision `
zed Agent City 1 ZIP
i ❑ CWEW PTA �SE
PTS Phone # ( ) ARiver Basin
❑ OEA ❑ HHF ❑ IH ❑ N/A Q� 1 ,
❑ PWS:
yes no PNA yes no
if Project/ Activity
Eck) length_U_'_:i
'latform(s) - ' X
Platform(s)
ength
ber
Riprap length
rg distance offshc
iax distance offsf�
:hannel //
ibic yards_
mph
use/ Boatlift
It
1
ie Length " It I
notsure yes no
rium: n/a yes
yes
Attached: yes no
ing permit may be required
Local Planning Jurisdiction)
A
)c t
Closest Mai. Wtr. Body TWO
❑ See note on back regarding River Basin
t

NC Division of Coastai Mgt. Habitat Impact Computer Sheet
Applicant: ���� Permit #:
Date: 1
l� JI
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measurement
found in your Habitat code sheet.
Habitat Name
Dredge ❑
P, V\j Dredge ❑
Dredge ❑
Dredge[]
Dredge ❑
-DISTURB TYPE
Choose One
Fill ❑ Both ❑ Other 4\
Fill ❑ Both ❑ Other
Fill ❑ Both ❑ Other ❑
Fill Both 0 Other El
Fill ❑ Both ❑ Other ❑
TOTAL Sq. Ft FINAL Sq. Ft. TOTAL. Feet,
(Appl ed..for. (Anticipated final (Applied for..
Disturbance total disturbance. Disturbance
includes any Exdudesany total includes
anticipated restoration any anticipated
restoration or andror temp . restoration or
temp impacts) im,-4 --' emp impacts.)
, �0
\` r�
FINAL Feet
(Ahtrcipated final
disturbance.
Excludes any
. restoration and/or
temp impact
amount
Dredge [❑
Fill ❑ Both El
Other ❑
Dredge ❑
.Fill ❑ Both ❑
Other
Dredge ❑
Fill ❑ Both ❑
Other ❑
Dredge ❑.
Fill ❑ Both ❑
Other ❑
Dredge ❑
Fill ❑ Both ❑
Other ❑
Dredge ❑
Fill D. Both ❑
Other ❑
Dredge ❑
Fill ❑ Both ❑
Other ❑ .
Dredge ❑
Fill ❑ Both ❑
Other ❑
Dredge ❑
Fill ❑ Both (1
Other ❑
Dredge ❑
Fill ❑ Both ❑
Other ❑

payment Proccessing Confirmation
Date Received 1 1/26/2017
heck From (Name) Matthew Hale (Money Order)
Name of Permit Holder Pauline Priest
Vendor Postal Money Order
Check Number 51254821754
Check amount $600.00
Multiple Permits No
Major/Minor
Permit Number/Comments GP 68020D
Receipt or Refund/Reallocated TM2862D

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONMAiVER FORM
Name of Property Owner: t? 1 4 �`�i HCA ►t��
Address of Property: �t>J�1 L ►it 1 1�.c�yQU 1"�C' V i�'`�U , �U C`"�
C `
(Lot or Street #, Street or Road, City & County) C
Agent's Name 1-kQ 1C Mailing Address:
Agent's phone #: „ _ 1�c= � - ` )C-D D CCAD
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 dravAng 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 90 days of receipt of this notice. Contact information for DCM offices is
available at http•//www nccoastalmanagement.netlweb/cm/staff-listinq or by calling 9-888-4RCOAST.
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, boat ramp, breakwater, boathouse, or lift 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.
Z.l I. I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
Print or Type Name
(Riparian Property Owner Information)
Sig ature
�I
Print or Type Nam
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