65079D - Gilbert

LAMA / d DREDGE &FILL
iENERAL PERMIT Previous permit #
qew EModification ❑Complete Reissue ❑Partial Reissue Date previous per issued
zed by the State of North Carolina, Department of Environment and Natural Resources .� « " , (U J
>astal Resources Commission in an area of environmental concern pursuant to 15A NCAC Rules attached.
_ ' NAk-7115OP4 Project Location: County _St•N�IW 1(
am
t 6t-A- 3 State ZIP* 1.'-' Vb
Fax # ()
;d Agentt-
-
❑CW ❑EW ❑PTA El ES ❑PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
❑ PWS: ❑ FC:
Street Address/ State Road/ Lot #(s)
i"c k t T
Subdivision
CiZIPu
Phone # ( ) River Basin (�
f
Adj. Wtr. Body t W �' Fat /rr,
Closest Mai. Wtr. Body A4 W VIJ
res / r PNA 'Yes / no Crit.Hab. yes / no
Project/ Activity _ bzx y x-i)�
(Scale: I" �

DENR CAMA Daily Check Log for WIRO
Date -7Check Check
Received Check From (Name) Name of Permit Holder Vendor Number amount Permit Number/C
3/2/2015 Pacula Builders LLC Roy Gilbert & Brenda Madison First Citizens Bank 1138 $600.00 GP 65079D

C Division of Coastal Mgt. Habitat Impact Computer Sheet
iplicant: Qoy Permit #: So 7
ite: 27 Z-7/1S
sscribe below the HABITAT disturbances for the application. All values should match the name, and units of measuremen
and in your Habitat code sheet.
ibitat 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.
Excludes any
restoration
and/or temp
impact amount)
TOTAL Feet
(Applied for.
Disturbance
total includes
any anticipated
restoration or
temp impacts)
FINAL Feet
(Anticipated fins
disturbance.
Excludes any
restoration and/
temp impact
amount)
-6
Dredge ❑ Fill P1 Both ❑ Other ❑
j �>O
�NA
Dredge ❑ Fill ❑ Both ❑ Other 0"
�
Z(cq
W L
Dredge ❑ Fill ❑ Both ❑ Other e1
Z (((J
v W
Dredge ❑ Fill ❑ Both ❑ Other 1,
-7 �(
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 ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑
Dredge ❑ Fill ❑ Both [I Other ❑
Dredge ❑ Fill ❑ Both 0 Other ❑

A
` NCDENR
North Carolina Department of Environment and Natural Resources
Division of Coastal Management
Beverly Eaves Perdue James H. Gregson
Governor Cirector
AGENT AUTHORIZATION FORM
Date 2 ' 1 q
Dee Freeman
Secretary
Name of Property Owner Applying for Permit: Nai of Authorized Agent for this project.
Owner's Mailing Address. Agent's Mailing Address:
Jk-Lid S
Phone Numberal 1 2-f Phone Number Lt,Q
I certify that I have authorized the agent listed above to act on my behalf, for the purpose of applying
f,Qr and obtaining all CAMP, Permits necessar install or construct the following (activity):
(my property located) at 3 (v �� Q_S�- ' t+-) r-y
r
This certification is valid thru (date) 1 2 3 C) • ��
Property Owner Signature Date
127 Cardinal Orlve Eq.. Wirra on, 4C 284o5
Phone: [phone] `� FAX: [phone] Inle rar. +ww.rrccas:a6rana;a rani ra;
An EQui O w wily 11 *Nmd a Aozc Er, abra!
NoIlrthCarolina
Naturallif

CERTIFIED MAIL . RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner:�U
Address of Property: � 8 �5� `� C��l�-�"��� +'✓`' �'
(Lot or Street #, Street or Road, City & County) AA
Agent's Name # bex-y, �� Mailing Address:
Agent's phone #:�L
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.
r�Illave 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. Contact information for DCM offices is
available at http://www.nccoastaimana_qement.netlweb/cm/staff-listing or by calling 1-888-4RCOAST.
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.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
(: �
Signature ;
Print o Type Name
Print or Type Name
Information)
I z 3 IA �-7 Li 6 o \ ( clay . sl,,4 D(
Mailing Address Mailinq Address

iy ' ��4� •` eJ � is ��:11
J
ADJACENT RTPARL-1-v PROPERTY OWNER STATE�LENT
I hereby certify that I own property adjacent to% { (j► J,�_�$yrp��
t(tt ame of Property Owner.
prorerTv located at
(Lot, B16ck, Road, etc.)
L-1
119 I�Z: • 8
on in ')G�::LS� a—yf-L , N.C.
(Waterbody) (Town and/or County)
Applicant's phone Ziling Address:
H.- has described to me, as shown below, the development he is proposing at that location, and, 1
have no objections to his proposal.
-------------------------------------------------------------------------------------------------------------------
DESCRIPTION A. D/OR DRAIA'ING OF PROPOSED DEVELOPI MNT:
(To he filled in by property owner proposing revelopment) \
err
Q� 64
------------------------------------------- ------
(Information for Property Owner Applying
for Permit)
Mailiniz Address
s

d--&e-/, ve.i
ADJACENT RIPARLA-N PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent top
Game of Property Owner)
property located at
(Lot, Blbek, Road, etc.)
L.-1
r
onC'�' ---- - — inc��� N.C.
(Waterbbody) Q (Town andior County)
Applicant's phone _25 - l� t(d ailing Address: l - � � ('�VAA
C)" a=:6 2
.-
He has described to me, as shown below, the development he is proposing at that location, and, I
have no objections to his proposal.
- - ----------------------------------------------
DESCRIPTION AIND/OR DRAWING Or PROPOSED DEVELOPIYIENT:
(To be filled in by property owner proposing development)
Coo' bv1�1R j-o�
i I
kAVV , Y-q
VA
64
----------------------- �� � �-> v__----------------------------------
(Information-------------------- -- for Property Owner Applying (Riparian Property Owner I,�formation)
for Permit) n //
rz
Mailing Address
Signature
I
r-

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATIONIWAIVER FORM
Name of Property Owner:
Address of Property:
(Lot or Street #, Street or Road, City & County)
Agent's Name #��c�� Mailing Address: � g 4,:) L)-
11-3
Agent's phone #: b 2-0 1 - ( c
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 proposing A description or drawing, with dimensions must be provided with this letter.
Wave 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. Contact information for DCM offices is
available at h ttp://www. nccoastaimana_qement. netlweb/cm/staff-listing or by calling 1-888-4RCOAST.
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 s Zo
the setback, you must initial the appropriate blank below.)
wish to waive the 15' setback requirement.
I do not wish to waive the 15' setback requirement.
(Property Owner Information)
Signature
�olr U e
Print o Type Name
(Ripar' Proper70wr Information)
a0-2
Signature
bA n
Print or Type Nam
Mailing Address
Mailinq Address

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