68597D - Robertson

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�CAMA / ElI DREDGE & FILL 1� �}1/ �1/ 8597 A B
GENERAL PERMIT Previous permit#
'New —Modification ❑Complete Reissue —'Partial Reissue Date previous permit issued_
orized by the State of North Carolina, Department of Environment and Natural Resources — ' 1 /-�
11 Coastal Resources Commission in an area of environmental concern pursuant to 15A NCAC O 1 (!"' oV
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.nt Name ) p Y1 R
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C �U U State C ZIP_2
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ized Agent OAti A3
d ❑ CWEW �TA ❑ ES ❑ PTS
❑ OEA � ❑ HHF ❑ IH ❑ UBA ❑ N/A
ElPWS:
yes / -no) PNA yes /
)if Project/ Activity
❑ u es attar
Project Location: County 9A'O�(Aenl K
Street Address/ State Road/ Lot #(s)
Subdivision
(,City 4> t x(^C V' ZIP ZD,
Ci
A Phone # 0 �;1 r Basin L-
Adj. Wtr. Body C�Riv1 � (nat
Closest Maj. Wtr. Body Al (/U 1
U
ding permit may be required by:
a I nr 1 Pinnnina hiricrlirtinn
fi(i M Q ( S('*o gA� % ❑ See note on back regarding River Basin
i

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit: �Q/JA `t�- �C" P-C4t4k'
Mailing Address:P,©cla3 ZS)-
Phone Number: cn YZ
Email Address:
I certify that I have authorized
e
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development: wc_'_-
at my property located at _5yi_5el ✓0t°ac�( /U
inAk%A_A1_ A1r _kCounty.
I furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
[�IL
Signature
go L:e a& ^
Print or Type Name
Title

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: _ -J�`,� C�� p, a —&I
Address of Property: 11-1 1D iL✓ -lD,e°; PA,
( (Lot or Street #, Street or Road, City & County) /-
Agent's Name #: ! )Ccl/i C//C p-Ri C e Mailing Address: _ / V
Agent's phone #: �/O MY"
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 Owner Inforn)ation)
Sigdhture
Print or Type Name
�DX
Mailing Address
(Adjacent Property Owner Information)
Signature
Print or Type Name
�2_3��,��
Mailing Address J

CERTIFIED MAIL - RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner: --i 0A- Q/v,/ D-e
Address of Property: /A c9 /,! s� 'o p �� � cx t [.ci�S �'
/(Lot or Street #, Street or Road, City & County)
Agent's Name #: per. ✓. c�1 akfc-,- Mailing Address: %fY 1 2 i 'r- �� 17�
Agent's phone #: //G? �j� S'—� lf-� 21-
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 Owner Information)
Sig ture
Print or Type Name
E, 0180V 6?1 �
Mailing Address
2f2�e>
(Adj ent Prr
Zer Information)
Signature
L� tP�m _,'� —
Print or Type Name
Mailing Address

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