69001D - Simmons

4CAMA / ❑ DREDGE & FILL pm 3.5, e- A B
3ENERAL PERMIT Previous permit #
(New ❑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 15A NCAC ��% �i • !y��
r ❑ Rules attached.
it Name M M o✓l Project Location: County
Street Address/ State Road/ Lot #(s)
A �� State �I � f ��! fti ;y)
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:ed Agent
❑ CW JKEW >PTA ❑ ES ElPTS
❑ OEA /❑IHHF /❑�IH ❑ UBA ❑ N/A
❑ PWS:
yes /6 PNA yes /
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rig permit may be required by: -To" 4 0,Q(,(0 1c &41 I. 1 ❑ See note on back regarding River Basin r
Local Planning jurisdiction) n_ I ^ I ` 1 1 r

NC Division of Coastal Mgt. Habitat Impact Computer Sheet
Applicant: M VL4 O ,, S Permit #:
Da
te:
oc�7
Describe below the HABITAT disturbances for the application. All values should match the name, and units of measuremen
found in your Habitat code sheet.
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
temp impacts)
FINAL Sq. Ft.
(Anticipated final
disturbance.
Exdudes any
restoration
and/or temp .
impact amount
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
I temp impacts)
FINAL feet
(Anticipated fins
disturbance.
Excludes any
restoration and/
temp impact
amount)
6
Dredge ❑ Fill ❑ Both ❑ Other N11(�
Dredge ❑ Fill ❑ Both ❑ Other 0
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge [] Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑. Pill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑ .
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both Q Other ❑
Dredge ❑ Fill ❑ Both 0 Other 0

■ Completd items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
Neb- S-�e.pheo s
A. Signature
❑ Agent
X ❑ Addressee
B. Received by (Printed Name) C. Date of Delivery
"5tgiN�r 2-13-1i
D. Is delivery address different from item 1? ❑ Yes
if YES, enter delivery address below: p No
t\�C
L
3, Service Type
❑ Priority Mail Express®
�II
II III
ICI
I III
I I
I II I II
IIII'II
I �I
III
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❑ Adult Signature
❑ dull Signature Restricted Delivery
❑Registered MaiIT"'
❑ Registered Mail Restricted
9590 9402 2129 6132 8927 86
t led Mail@
C ified Mail Restricted Delivery
Delivery
❑ Return Receipt for
Merchandise
❑ Collect on Delivery
El Collect on Delivery Restricted Delivery
❑ Signature Confirmation TM
2. Article Number (transfer from service label)
❑ Insured Mail
❑ Signature Confirmation
all Restricted Delivery
Restricted Delivery
7016 2140 0000 9310 7618
-
Domestic Return Receipt
PS Form , July 201 PSN 7530-0 -
U.S.
Postal
Service''°
CERTIFIED
MAIL°
RECEIPT
Domestic
Mail
Only
N •e bsrt..' www.usps.com''.
For delivery
information,
visi
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CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Wii:TRIM
Address of Property: �?o (1iT�n�uG ; o,v ST
(Lot or Street #, Street or Road, City & County)
Agent's Name #: Hal Kko Mailing Address: / r'o / fcHr�✓Ta.� t
Agent's phone #: _cl ►b 49`6o c/ 3 _ T 80 N L Z -K -/tiq
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.
r Information) (Adjacent Property Owner Information)
Z—
Print or Type Name
Mailing Address
Signature
S ► P�1-,vS
Print or Type Name
l 5ov J E1VKTW,5
Marling Address

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to �- ; rin„v S Sca�1 ws� 's
property located at
(Name of Property Owner)
�,�,.. , o N � _
( ddress, Lot, Block, Road, etc.)
on _�AT�eAt AN�� in _ ©cQ"�.�- - -.X. (�' - N.C.
(Waterbody) (City/Town and/or County)
The applicant has described to me, as shown below, the development proposed at the above location
I have no objection to this proposal.
I have objections to this proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(Individual proposing development must fill in description below or attach a site drawing)
1•� S��<< � I �I�
S'
Ni"19NS WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back
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 'acent Property Owner Information)
�,
C, -- � 14 P J Va)
Signature Signature
aL 4�-,?MM,rS C���c00%✓� �lQ'.`o. \ �. \�o.NcAcLL
Print or Type N me Print or Type Name
1� l,): n;� a✓ �� . ��1Z Dam i-1c /Jar 11JC .
A/..711„— d�IJ____

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