76513D - Gilmore

CAMA / ❑ DREDGE & FILL N9 76513 A B
i WY E RAL PERMIT Previous permit #
New El Modification [-]Complete Reissue El Partial Reissue Date previous permit issued
zed by the State of North Carolina, Department of Environmental Quality
:)astal Resources Commission in an area of environmental concern pursuant to I SA NCAC n H
❑ Rules attached.
Name Project Location: County�-
., (�Q -A Street Address/ State Road/ Lot #(s) 2 9 O
Q%NSJ StateZIP
LI rl (y G 5� E-Mail e b CA M oip- (&r�,p .I.Subdivision
.d Agent City ZIP
❑ CW in EW TA
❑ ES ElPTs Phone # () River Basin
ElOEA ❑ HHF IH ❑ UBA ❑ N/A
❑ PWS:
res / !' D PNA yes /
gth
fiber
I Riprap length
distance offshore
distance offshon
innel I
is yards
P
e/ Boatlift
Length
Adj. Wtr. Body W %A 01W
Closest Maj. Wtr. Body U% Q
was
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not sure yes �fbi
um: n/a yes
yes
ttached: J no
ig permit may b� `quired by:
.ocal Planning jurisdiction) _.
- 1 n . , ,
511
❑ See note on back regarding River Basin rc
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CERTIFIED MAIL • RETURN RECEIPT REQUESTED
DIVISION OF COASTAL MANAGEMENT
AD.iACIE,NT RIPARIAN PROPERTY OWNER - I 1 NOTIFICATION/IJI WAIVER FORM
Name of Property Owner.
Address of Property:
(Lot or Stree`#, St E
Agent's Name
Agent's phone
or Road, City & County)
Mailing Address: � D , 4,�
Him
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 descrintion or drawing with dimensions must be provided with this letter.
( I have no objections to this ro osal.
P p I have objections to this proposal.
/f you have objections to whatis 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 ou 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
,vish 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)
ignature
ynt or Type Name
ailing Address
(Adjacent Prope w er Information)
ignature c
Pnnt or Type Name
?40 �a th L.�ullc S w
Mailing Address'

AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION
Name of Property Owner Requesting Permit:��
Mailing Address: oZ 9 Cy-L-X-\ \JJq \ i�
Phone Number:
Email Address:
I certify that I have authorized
II \ MC-r''0— & "CYr'4 k t , C" M
\-\ C7)\C1 'e- I --�
Agent / Contractor
to act on my behalf, for the purpose of applying for and obtaining all CAMA permits
necessary for the following proposed development
at my property located at
inCounty.
1 furthermore certify that I am authorized to grant, and do in fact grant permission to
Division of Coastal Management staff, the Local Permit Officer and their agents to enter
on the aforementioned lands in connection with evaluating information related to this
permit application.
Property Owner Information:
Signature
Print or Type Name
Title

nplete items 1, 2, ana o.
it your name and address on the reverse
that we can return the card to you.
ach this card to the back
t the mailpiece,
on the front if space pe
icle Addressed to:
0 eilelk, l�
II "I'I'� I'II I'I I II II'II II I II I II II I'I I I I I I I I II
9590 9402 2597 6336 4682 65
1-016 416p0 0000 5521 667i
Form 3811, July 2015 pSN 7530-02-000"9`
P!TJnN ON DELIVERY
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e tered MailT"
Mail RestricteA
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7 Ad
Adult Sign
❑ Certified Mail®
I
Delivery
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❑ Certified Mail Restricted Delivery
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Domestic Return Receipt