69035D - Taff

Project Location: County Nr o[ 0, h v v f r
Street Address/ State Road/ Lot #(s)
R4CQ_C�
SubdivisionLJ
CityJAM I V.1 fL ± " 1 4+1 ZIP
Phone # ( ) River Basin
Adj. Wtr. Body , l V
Closest Maj. Wtr. Body J,V
,LAMA / DREDGE &FILL T14-Y.5-17 A B
GENERAL PERMIT Previous permit #
New ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
•ized by the State of North Carolina, Department of Environment and Natural Resources ��}} JJ
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC ll �' 1 •' 7 y}
❑ Rules attached.
t Name J KtAl
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V ie w State Ai ZIP
1 91 U l E-mail
ed Agent ,
❑ CW )Y" �1 PTA El ES ElPTS
❑ OEA ElHHF /❑ IH ❑ UBA ❑ N/A
❑ PWS:
no PNA yes /(no
f Project/ Activity
atform(s) ' ' IU
Platform(s)
�S
ling permit may be required by:�a i1()lv F % ` 0 U Plf*",Y ❑ See note on back regarding River Basin

Complete 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.
Article Addressed to:
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B. jiey ' ed by P ' m C. ate of Delivery n)
D. Is delivery address different from Item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
ago
3. Type
❑ Priority Mall Express®
II I �III�I I II I�I I II I �IIIII�I I I I II
Adult i
❑ Adult Signature
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❑ Adult Signature Restricted Delivery
❑ Registered Mail Restricted
9590 9402 1453 5329 6184 41
° Certified Mal®
Delivery
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❑ Certified Mail Restricted Delivery
❑ Return Receipt for
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❑ Collect on Delivery
Merchandise
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n r..ilect on Delivery Restricted Delivery ° Signature Confirmation-
° R'egstrictred Delivery lion
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Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt
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NC Division of Coastal Mgt. Habitat Impact CC.-APUter Sheet
Applicant: ` � 4WAA)
Permit #: �C3S
Date: J 1;1 (4-
Describe. below the. HABITAT disturbances for the application. All values should match the name, and units of measurement
found. in your Habitat code sheet.
N,4L Feet
Habitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft
(Applied for.
Disturbance total
includes any
anticipated
restoration orp
temimpacts)
FI
FIN
(An'
di
im
Dredge ❑
Fill ❑
Both El
Other
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill El
Both ❑
Other ❑
Dredge ❑
Fill [I
Both ❑
Other ❑
Dredge ❑
Fill [I
'Both El
other ❑
Dredge El
Fill ❑
Both El
'Other ❑
Dredge El
Fill ❑
Both ❑
Other ❑
Dredge ❑
Flit ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑
Fill ❑
Both ❑
Other ❑
Dredge ❑ Fill El Both ❑ Other ❑
Dredge [I Fill ❑ Both El Other [1
Dredge ❑ Fill ❑ Both ❑ Other El
Dredge ❑ Fill ❑ Both El Other ❑
Dredge 0 Fill ❑ Both El Other ❑
L Sq. Ft.
nuance.
Fxdudes
restoration
and/ortemp
TOTAL Feet
i for.
F[
(Anticipated final
ppated final
(App I+ed
Disturbance
total includes
disturbance.
Excludes anY
any
any anticipated
restoration and/or
_
restoration or
temp imPad
amount) __
temp impacts
amounQ

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CCDE HR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Drly Eaves Perdue James H. Gregson lee Freeman
ernor Director Secretary
AGENT AUTHORIZATION_ FORM
Date: —/ 7 - / 7
e of Property Owner -Applying for Permit:
er's Mailing Address:
ne Number
Name of Authorized Agent for this project:
w 6kc
77 -
Agenes. Mailing Address`-
(a
Phone Number ax-)_ ! 3 E-- .
tify that i have authorized the agent listed above to act on my behalf, for the purpose of applying
obtaining a�fI GAMA Permits necessay to install or construct the
1 I
property located) of
certificatiort is valid thru (date) l2
ED
Property Owner Signature Date

CL RTIFIFD IViA1I, —RETMN RECE11'T REQUESTED
DIVISION OF COASTAL MANAGEWINT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner: (fn �GcT
Address of Property:
(Lot or Street #, Street or Road,
!Z C.
,/� County)
_r.
Applicant's phone #: �5�— 3�/�—��g Mailing Address: 6 _oX 17 (off
/vec..ts
I hereby certify that I own property -
p perry 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 proposutK. A desci i tiun r f dr9WiW
with dimensions. musl be provided_ with this letter.
I have no objections to this proposal I have objections to this proposal.
If ydU ha4*biections to what is being proposed, you must notify the Division of Coastal Management (Dt�
in writing within 10 days of receipt of this notice. Correspondence should be mailed to l27 Cardinal Drive Ext.
consider ton, e s me as 3tit45. D- W representatives can also be contacted at (910) 796-7Z15. No res
considered the same as no ob'ecrion if ou have been noticed by Certified Maio
WAIVER SECTION
i understand that a pier, dock, mooring pilings, breakwater, boathouse, or lift must be set back a minimum distance of
15' fror$ my area of riparian access unless waived by me. (If you wish to waive the setback, you m�nst
aPProPoate blank below.) 4i the
_ I do wish to waive the 15' set back requirement.
not wish to waive the 15' set back requiremem
(Riparian
-AVICLU Ca — -
j ; signature
Print or I'Names
Print or Typt In
Mailing Address I' SJ� 9)6-6A
11111 Mailing Address
'A GCS. C 27, '3 S'
City / State I Zip -� -- City IState /Zip
Telephone Number xD V`
Information)
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CERTIFIED MAIL — RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MMNAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
Name of Property Owner:
Address of Property:
(Lot or Street #, Street or Road, City & County)
C, loe, u N�a
Applicant's phone #: 2S�- 3y%''I t D Mailing Address: P 6. 6 oX 17 (,c,
I hereby certify that Ipwn 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 dcsce I tioa of drawing,
with dimensions, must be provided with this letter.
u, �F1�05 Scajve
i 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 wailed to 127 Cardinal Drive Ext.
Wilmington, NC 28405-3845. DCM representatives can also be contacted at (910) 79&7215. No response is
considered the same as no objection if you have been notified by Certified Mail.
WAIVER SECTION
I understated that a pier, dock, mooring pilings, 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.)
(P
I do wish to waive the 15' set back requirement.
V* tom, S w G=
not wish to waive the 15' set back requirement:
or Type
(Riparian Property Owner Information)
Signature
Print or Type Name
C?/50x 12& G 01217 S �nns� �( a(W v -F-cu� v r•rL, (�
Mailing Address Mailing Address
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CERTIFIED MAIL — RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPA
RIAN PROPERTY OWNER STATEMENT
Name of Property Owner.
Address of Property: New j {c, �.
(Lot or Street #, Street or Road, 05 & County)
Applicant's phone
Mailing Address: 0, t3oX 17 (ac,
-z D. 1 -1 ,++C, I r-, S A 1,U1 ,,-e_ Xi
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I hereby certify that Down 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 de:set iption of 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 Eat
Wilmington, NC 28405-3M5. 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, or lift must be set back a minimum distance of
15' from rrty area of riparian access unless waived by me. (If you wish to waive the setback, you must initial the
appropriate blank below.)
t I do wish to waive the 15' set back requirement.
not wish to waive the 15' set back requirement
(Riprian Property Owner Information)
Fvv-
Signature
TOM I. U7/
Print or Type l�atn Print or Type Name
e-- 01Sax /? G 0117 Ste°�,6/ '"s�_ aka 6 �c� u (±
Mailing Address Mailing Address
2-MS'-

CERTIFIED MAD, — RETiFILN RECEIPT REOUTESTED
DIVISION OF COASTAL MANAGEACM
ADJACENT WARL4N PROPERTY OWMM STATEMENT
Name of Property owner:
Address of Property:
&T
(Lot or Street #, Street or
6-411— ,000 C-
A county}
Applicant's phone 8: Mailing Ate: A
I heaieby certifp that I orvn pP�y u: �� • C
e above arpert
has descraed to me as nefa+ed 1Oy �Q applying � this permit
w h dimensi �yidod with this dmvving &a developme" they am pr Vmiq;' Aa iuti�u of drawiwi�
no obj=dm to this proposal. I nave objet oas to this
proponj
If "i«+�o�a ah noo- ' ye° ttttnr "dry the Divisititt arCeaadt t (nC Mi
to write � lA
NC gyps- VC C ° 4- n 1d k nailed I27 Catdisai Dove EYt.
caasidered We chn.. �eatativ� CSM also be eostactd at (%a) 796.
215_ No r,e�spoa�
as no ob' i+n .f on base been nwif6a Lm re..:�_� x._..iq
I end tbat a Per, dock, WAIVER SECTION
15' my then of ' mooring pd�' b=kwater, boathouse, or lift must be set back a nimimnut list wee of
{ rotriaa access unless waived by me. (If you wish to waive tin+ vpmpnak blank belay} SC"dc, you Mast it"'W the
--1 d' wish to waive the IS' set back requfiunent.
Rot wish to ware the t 5' set beck
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Mailing
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