69454D - Shepard

CAh1A / ❑ DREDGE & FILL I I A B
iENERAL PERMIT Previous permit#
flew CModification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
zed by the State of North Carolina, Department of Environment and Natural Resources 4-
/h� 1 f � ri (,�'
)astal Resources Commission in an area of environmental concern pursuant to I SA NCAC P; � i ❑ Rules attached.
Name IW�L (` Project Location: County r�p i,�,'6t Y1iyN r
LT V �, it b DY 1X r LC Street Address/ State Road/ Lot #(s) ' IX, A 1. Y1 I
1 State__ ZIP J-n
E-Mail AIj R Subdivision I 1
ad AgentTEW
City l,v Yti�11�15► } �'1 e 17t �(.L� ZIP 2C24i- 64
❑ CW A ❑ ES ❑ PTS , hone # (q � ) River Basin _❑ OEA IH ❑ UBA ❑ N/A Adj. Wtr. Body n �' 6t h nat
❑ PWS: � I1/
Closest Maj. Wtr. Body
no yes / PNA yes / ,
Project/ Activity
-k) length
itform(s)
01
Platform(s) X Zq
ne Length -+/- 5LP
0
0
4 06 Kino
(Scale: tl
yes �rrT--G
Attached: es no"
<AJJ?eV
Ping permit may be required by:
IT ( L,y " I C, .- ,U��u' El See note on back regarding River Basin

CERTIFIED MAIL RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
ame of Property
Owner:
Jdress of Property: (Lo or Street #, St eet or oad, City & count
gent's Name #: Mailing Address.
� ' r--�=�, i-
,gent's phone #: _ 1 U
hereby certify that I own property adjacent to the above referenced property.
The individual
1pply-ng for this permit has described to in with dimattached on the drawing
ensions must berovided weth development
he re roposing. A descri ton or drawm
V I have no o 'ections to this proposal. I have objections to this proposal.
9`SPrmg ,�jJltctlfmo rIbmia DOth-
rf you have objections to what is being proposed, you must notify the Division of Coastal Management (DCM) in
Wilmington,
within 10 days of receipt45.Dcm can also be contacted at (910)spondence should be mailed to 127 Cardinal Drive Ext.,
796-7215. No response is
Wflmington, NC, 28405.3845. Drepresentatives
--ncidared the same as no ob ection if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, ea of accesshun unless waived roin must by me (if be
t
back a minimum distance of 15 from my a pro appropriate blank below.)
wish to waive the setback, you must initial the app p
I do wish to waive the 15, setback requirement.
I do not wish to waive the 15' setback requirement.
Property Owner Information)
(Adjacent Property Owner Information
Signc ire
Signature
Print or Type Name
Print or Type Name
L�%i �-� 1►� 1c'U iir� Mailing Address
�,

r• �RTL RETt tRN RECEIPT i ;:WESTEO
;}}(ISM OF COASTAL MANAGEMENT
At3.1ACENT RIPARMN PROPERTY OWHER NO-rtHCATIOr, MAIVER FORM
Mama of property
goner
Address of property
tL 1 or Street a, S t or , �d. City 3L County? ,
Mxne�
,4gsrs t._r t3
Agent's phone tk %
1 hereby ceNfy
that I own property acjacent to the above referenced property The individual
for thts permit has described to me as shown on the attached drawing idQ�� this i6ttar.
applying naasn[)➢oy� a uot+ " •,"iieme.lons must tie artrL
,they are proAosing'
I have no objectiam to this proposal.
I have objections to this prop0303.
jC •iri'LA;-1 Dft4;lr X ! 1 r i s!1 f,� c .f�
1f you have ob}acttons to what A berng proposed)YOU mustnotity the DHtafon olGoaatar Mane anent (DCLi) yn
if
rve Ob 10 days O resarpt &this nc�ttca Conospondenc* ahoufd be mefAd $0127' Cardhwt Qrtve Ext,
Of siso be cafthw d at iP10) 7D&721& No r"Ponse Is
i�YriM ogt", NC, 2&AOd &4& DCW mPr"wxhtdvns can Corttfied Mau.
m u no tlon N have been r►odfiod
cnn
wAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, rrn, or groin must be set
back a minimum distance of 15 from my area of ripatian access un3ess waived by me. Of YOU
wish to waive the setback, you Muet initial me appropriate blank below )
M/ t do wish to waive the 1 S setback requirement
i do not wish to waive the 15 setback requirement
�roperqi Lowner Iniormatlon)
ignature r
Pnnt or Type Nerve
Mailing AtdOSS
CitlrlSta
Jr '
1 ir1
{Adjac�e-nt— property
,�!�yli''-^-� formstiai
Signature
Pant or Type Name
�
Iir
bleNing Ad rsss
Gity/Stay P
elephone Number

�c� t� 6 Zp17
NCDENR
North Carolina Department of Environment and Natural Resources
John E. Skvarla, III
,Tory Secretary nor
N.C. Division of Coastal Management
AGENT AUTHORIZATION FORM
Date:
for Permit: Name cif Authorized Agent for this project:
of Property Owner Applying �`'
is Mauling Address'
!' 6 VAl�nZ
n�C�1�t1)i L�
7
Agent's (Maiiling Address:
l L,ki i C J& &, ,,;
Email: t+
Phone (ILI 931— 8 55%7
ify that I have authorized the agent listed above to act on my
behalf, for the purpose of applying
ind obtaining all CAMA Permits necessary tIo install or construct the following (activity):
my property located at
certification is valid 1 year from (date)
VG,