65103D - Michael

I.CAMA / ❑ DREDGE & FILL jp �o
1ENERAL PERMIT Previous permit#
INew ❑Modification ❑Complete Reissue ❑Partial Reissue Date previous permit issued
-ized by the State of North Carolina, Department of Environment and Natural Resources / H I 2-L) J
:oastal Resources Commission in an area of environmental concern pursuant to 15A NCAC
❑ Rules attached.
Name W;M N► C, A\ i L N'Ri"L. Project Location: County \ t J 5Lv I ((L
' / 1 SL yty 0 State tA, ZIP 2 IC �
ed Agent OOWO SC J)iA C1V L A
-: CW ['] EW ;PTA ❑ ES ❑ PTS
❑ OEA ❑ HHF ❑ IH ❑ UBA ❑ N/A
1 - PWS: ❑FC:
yes / no PNA ?es / no Crit.Hab. yes / no
Street Address/ State Road/ Lot #(s)
Subdivision
City () 1 c' L- ,4� ZIP 7's"1
Phone # ( )
River Basin ( I`'YL
Adj. Wtr. Body A-IW Vv ( �l
Closest Maj. Wtr. Body /� ICJ A
Project/ Activity Na V 01 I Lye, y J L Lc \tom tv
(Scale:
:k) length � � V (r *'
U' Z' er(s) -7 x
igth
nber
I/ Riprap length_
distance offshore
x distance offshore
annel
ric yards
ip 1
se/ Boatl' G, X 3 i
E ( Q.'A-'X ti
Aldozing
F► OAl 2�5
Length
not sure yes
not sure yes
iunn: n/a yes nd
yes
ltached: yes no —
J 1ti0
ig permit may be required by: 0 CSC (��rirA
❑ See note on back regarding River Basin n

CDaits
MHCDO
Tyler Crumbley
LPO
DW Review
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■ Complete,.items 1, 2, and 3. Also complete
A.
item 4 if Restricted Delivery is desired.❑
■ Print your name and address on the reverse
X Agent
so that we can return the card to you.
❑ Addressee
6ecei've
(Printed Name)
C. Date o elivery
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
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1. Article Addressed to:
D. Is delivery address different from item 1? Ye
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If YES, enter delivery address below: El No
3. Service
❑
7MaiI00
Certifrity Mail Express'"❑
Regisurn Receipt for Merchandise7-7,4i%)Q,
L� C/
❑ Insurect on Delivery
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 7013 3020 0000 7304 0543
(Transfer from serv. , label)
PS • i11, jui� '013 Domestic
(Domestic ar n y;
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For delivery information visit our website at www.usps.com®
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IC Division of Coastal Mgt. Habitat impact Computer Sheet
pplicant: qlfNNISlb'IIcC `L Permit#; (O5kO-�s
ate: 'I-] 21r s
ascribe below the HABITAT disturbances for the application. All values should match the name, and units of measuremer
fund in your Habitat code sheet.
abitat Name
DISTURB TYPE
Choose One
TOTAL Sq. Ft.
(Applied for.
Disturbance total
includes any
anticipated
restoration or
ternimpacts)
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 fin
disturbance.
Excludes any
restoration and
temp impact
amount)
b W
Dredge ❑ Fill ❑ Both ❑ Other El"
03
1 (035
1--iM
Dredge ❑ Fill ❑ Both ❑ Other 0
t 9-O
( �O
Dredge ❑ Fill ❑ Both ❑ Other 011
Cl Z
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 ❑ Other ❑
Dredge ❑ Fill ❑ Both 0 Other ❑
Dredge ❑ Fill ❑ Both ❑ Other ❑

CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name of Property Owner.�e�t1�S�C�1C9-�L
Address of Property: JC��
(Lot or Street #, Street or Road, City & County)
Agent's Name #�PJ����Gr_t��� Mailing Address. -
Agent's phone #:
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. Contact information for DCM offices is
available at http://www.nccoastaimanagement.netlweb/cm/staff-listing orby 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.
(Propert pwner Information)
Signature
Print or Type Name
(Ri
C�, N
Print or Type Name
er Information)
LlVw G��� �slti Ot .
Mailina ArlrlrP.c.e
Mailinq Address

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